Citation Nr: 1807324 Decision Date: 02/05/18 Archive Date: 02/14/18 DOCKET NO. 07-18 498 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to service connection for bilateral Achilles tendonitis. 4. Entitlement to an initial rating in excess of 20 percent for lumbar strain. 5. Entitlement to an initial rating for a scar of the vermilion border of the mid-upper lip, rated noncompensable prior to April 22, 2016, and 30 percent from April 22, 2016. 6. Entitlement to an initial rating for a scar of the abdominal area, rated noncompensable prior to 22, 2016, and 10 percent from April 22, 2016. 7. Entitlement to an increased initial rating for osteoarthritis of the right knee with patellofemoral syndrome, rated 10 percent disabling. 8. Entitlement to an increased initial rating for osteoarthritis of the left knee with patellofemoral syndrome, rated noncompensable prior to March 5, 2009, and 10 percent from March 5, 2009. 9. Entitlement to a compensable rating for pseudofolliculitis barbae (PFB). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 1983 to September 1983, from January 1992 to May 1992, and from August 2004 to February 2006. This case comes to the Board of Veterans' Appeals (Board) on appeal of rating decisions of the Nashville, Tennessee, Regional Office (RO) of the Department of Veterans Affairs (VA). In February 2015, a videoconference Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. Among the issues developed and certified for appellate consideration were entitlement to service connection for a left knee disorder and entitlement to service connection for neurologic disorders secondary to service-connected disabilities. By rating decision dated in August 2011, service connection was established for small fiber neuropathy of the lower extremities. By rating decision dated in March 2012, service connection was granted for small fiber neuropathy of the upper extremities. In October 2014, service connection was established for degenerative joint disease (DJD) of the left knee. The Veteran has not indicated disagreement with the evaluations assigned for the upper or lower extremity neuropathies or for the left knee disability. As such, these issues are no longer on appeal. This case was before the Board in July 2015, when some issues were decided and other issues were remanded. During the pendency of this appeal, service connection was denied for chronic cystitis, Tarlov cyst, bilateral Achilles tendonitis, bilateral metatarsalgia, bilateral great toe pain, and a left shoulder disability. In correspondence and at his hearing on appeal before the undersigned, the Veteran indicated disagreement with these denials. Disagreement was also evidenced to the noncompensable rating assigned for service-connected PFB. These issues were considered to be before the Board and a Statement of the Case (SOC) was issued in response to these notices of disagreement. Manlincon v. West, 12 Vet. App. 238 (1999). In response to the SOC, the Veteran appealed the matters of service connection for right and left shoulder disabilities and bilateral Achilles tendonitis. As such the only issues that remain on appeal are those listed on the title page. Hence the remaining issues are not properly before the Board. 38 U.S.C. §§ 7105, 7108 (2012); 38 C.F.R. § 20.302(c) (2017); Roy v. Brown, 5 Vet. App. 554 (1993). The issue of an increased rating for PFB is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if additional action is required on his part. FINDINGS OF FACT 1. A pre-existing right keloid scar of the right shoulder did not increase in severity during service and is not shown to be related to a current disorder of the right shoulder. 2. A current right shoulder disorder was not manifested during service or until several years thereafter; DJD of the right shoulder was not demonstrated within the first post-service year. 3. A current left shoulder disorder was not manifested during service or until several years thereafter; DJD of the left shoulder was not demonstrated within the first post-service year. 4. Achilles tendonitis was not demonstrated during service or thereafter. 5. For the period prior to April 22, 2016, the service-connected scar of the vermilion border of the mid-upper lip is shown to be manifested by a scar measuring 0.25 cm. by 1 cm, without tenderness to palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown, underlying tissue loss, elevation or depression of the scar, disfigurement, or in duration or inflexibility. 6. For the period from April 22, 2016, the service-connected scar of the vermilion border of the mid-upper lip is shown to have been productive of a disability picture of scars with two or three characteristics of disfigurement, but not visible or palpable tissue loss, gross distortion or asymmetry of two features or paired sets of features, or four or five characteristics of disfigurement. 7. For the period prior to March 5, 2009, the Veteran's abdominal scarring measured about 2.0 cm by 0.1 cm and 0.5 cm by 0.1 cm, without tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, or abnormal texture. 8. On examination on March 5, 2009, the Veteran's abdominal scarring was noted to be painful. 9. On examination on June 25, 2011, the Veteran's abdominal scarring was shown to measure 1 cm by 6 cm, with an area of less than 6 square inches; without pain, sign of skin breakdown, edema, keloid formation, or other disabling effects. 10. On examination on April 24, 2016, the Veteran's abdominal scarring was shown to cover a total area of 1 cm2, with pain that was dull and aching without touch and sharp to touch; without frequent loss of covering of the skin over the scars or instability. 11. Throughout the appeal, from the effective date of service connection, the Veteran's right knee disability has been manifested by slight DJD, pain and limitation of flexion that would be considered noncompensable under regular schedular rating criteria; other impairment such as lateral instability, repeated subluxation, or limitation of extension is not demonstrated. 12. Throughout the appeal, from the effective date of service connection, the Veteran's left knee disability has been manifested by slight DJD, pain and limitation of flexion that would be considered noncompensable under regular schedular rating criteria; other impairment such as lateral instability, repeated subluxation, or limitation of extension is not demonstrated. CONCLUSIONS OF LAW 1. A chronic right shoulder disorder was neither incurred in nor aggravated by service, nor may DJD of the right shoulder be presumed to have been. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 1153 (2012); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309 (2017). 2. A chronic left shoulder disorder was neither incurred in nor aggravated by service, nor may DJD of the left shoulder be presumed to have been.. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 1131, 1137, 1153 (2012); 38 C.F.R. §§ 3.303, 3.306, 3.307, 3.309 (2017). 3. Achilles tendonitis was neither incurred in nor aggravated by service. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2017). 4. The criteria for an initial compensable rating for a scar of the vermilion border of the mid-upper lip were not met prior to April 22, 2016. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.114, Diagnostic Code (Code) 7805 (2017). 5. The criteria for an initial rating in excess of 30 percent for a scar of the vermilion border of the mid-upper lip have not been met from April 22, 2016. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Code 7800 (2017). 6. The criteria for an initial compensable rating for scar of the abdominal area were not met prior to March 5, 2009. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.114, Diagnostic Code (Code) 7805 (2017). 7. The criteria for an initial rating of 10 percent for scar of the abdominal area were met from March 5, 2009, to June 24, 2011. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Code 7804 (2017). 8. The criteria for an initial compensable rating for scar of the abdominal area were not met from June 25, 2011, to April 21, 2016. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.114, Diagnostic Code (Code) 7805 (2017). 9. The criteria for an initial rating of 10 percent for scar of the abdominal area were met from April 22, 2016. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.118, Code 7804 (2017). 10. The criteria for an initial rating in excess of 10 percent for a right knee disability have not been met for any period. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Code 5262 (2017). 11. The criteria for an initial rating of 10 percent for a left knee disability were met for the entire appeal period. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.71a, Codes 5003, 5260 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's duty to notify was satisfied letters dated in April 2008, February 2009, June 2009, December 2009, April 2010, April 2010, and March 2014. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in October 2016. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examinations obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2017). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111 (2012). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b) (2017). A pre-existing disorder will be considered to have been aggravated by active military service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disorder. 38 U.S.C. § 1153 (2012); 38 C.F.R. § 3.306(a), (b) (2017). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the "correct standard for rebutting the presumption of soundness under Section 1111 requires the government to show by clear and unmistakable evidence that (1) the veteran's disability existed prior to service and (2) that the pre-existing disability was not aggravated during service." The Federal Circuit noted that the lack of aggravation could be shown by establishing there was no increase in disability or that any increase in disability was due to the natural progress of the pre-existing condition. See Wagner v. Principi, 370 F.3d 1089, 1096-97 (Fed. Cir. 2004). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a) (2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Right Shoulder Disorder The Veteran contends that he has a right shoulder disorder that had its onset during service. During the Board hearing in February 2015, he asserted that he injured his shoulder while lifting weights while on active duty. As noted above, neurologic disability involving each upper extremity, which the Veteran testified as being related to his service-connected cervical spine disease, has been service connected and is no longer part of the current appeal. Review of the record shows no pertinent abnormality on examinations conducted for service in 1983 and 1989, but an examination in January 1992 showed that the Veteran had a keloid skin condition. Additional evaluation showed that he had a keloid scar of the right shoulder, which was found to have existed prior to his last period of active duty. Treatment for this scar was undertaken in October 2005, which included a Kenalog injection. An examination was conducted by VA in November 2005, prior to the Veteran's discharge from service in February 2006. At that time, it was noted that the Veteran had been suffering from right shoulder pain and scar due to steroid injections. This had existed since 2004. It was noted that this was due to an injury that had occurred in a pre-mobilization training exercise. The symptoms included slight pain, stiffness and popping noise. Physical examination showed no limitation of motion. X-ray studies were found to be within normal limits. Regarding the Veteran's right shoulder scar, it was noted that there was slight pain, stiffness in the scar. There was no limitation of pain, fatigue, weakness, lack of endurance or incoordination following repetitive use. The diagnosis was right should condition with scarring. A private May 2009 MRI study of the right shoulder showed findings consistent with supraspinatus tendinopathy with a questionable tiny articular surface and partial thickness tear at its insertion. An X-ray study conducted in connection with a September 2009 VA examination showed no evidence of fracture or dislocation, but there was very slight degenerative changes of the acromioclavicular (AC) joint noted. An examination was conducted by VA in April 2016. At that time, the diagnoses were right shoulder strain, right DJD of the AC joint, bilateral labral tears, and right shoulder keloid scar. The examiner was requested to render an opinion regarding whether the right shoulder disorder that pre-existed service had been aggravated beyond the normal progression by service. The examiner rendered an opinion that the Veteran's right shoulder condition was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran had a preexisting keloid scar of the right shoulder that was treated with a Kenalog injection during service. During the examination, the Veteran was referring to a right shoulder strain that is a separate condition from a keloid scar and that, therefore, no aggravation could be noted. Regarding the additional right shoulder disorders noted on examination, the examiner opined that it was less likely than not that these were incurred in or caused by a claimed in-service injury, event or illness. The rationale was that the Veteran's STRs showed a left shoulder strain in November 2004 that appeared to be acute and transitory in nature. The MRI report in 2009 showed bilateral labral tears of both shoulders with minimal DJD to the right. The examiner could not provide a causal connection between an acute strain of the shoulder in 2004 with DJD of the right shoulder and labral tears in 2009. It was felt that further injury or wear and tear occurred after the 2004 incident causing progression of the diagnosis as there was only one report of a right shoulder strain in 2004 that was believed to be acute and transitory. Review of the record shows no evidence of a right shoulder disability during either of the Veteran's first two periods of active duty, which were during 1983 and 1992. Prior to the period of active duty that began in 2004, keloid scarring, including a keloid on the right shoulder was noted. While he testified that he had a right shoulder strain in 2004, the only medical opinion in the record is that the strain was acute and transitory in nature such that it did not result in the chronic disorders that were first demonstrated in 2009, three years after the Veteran's last separation from service. Moreover, that opinion confirms that there is no relationship between the keloid scarring noted at entry into service and the later development of shoulder strain and DJD and that the keloid did not increase in severity during service. In the absence of a medical opinion that supports the establishment of service connection, either directly or through aggravation, the claim must be denied. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a right shoulder disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2017). Left Shoulder Disorder The Veteran is also claiming service connection for a left shoulder disorder that he testified is related to a left shoulder stain that he sustained in 2004, during service. Review of the STRs shows no left shoulder complaints in the record prior to the pre-discharge VA examination that was performed in November 2005. At that time, the examiner stated that the Veteran reported having injured his left shoulder during a pre-mobilization training exercise, with symptoms of pain, stiffness and a popping sound. Examination showed normal range of motion. X-ray studies of the left shoulder were within normal limits. The diagnosis was that there was no diagnosis of a left shoulder condition as there was no pathology to render a diagnosis. Post-service treatment records include the results of a September 2009 VA examination that showed some limitation of motion of the left shoulder. X-ray studies showed no evidence of fracture, dislocation, focal osseous lesions, joint effusion or DJD. An examination was conducted by VA in April 2016. At that time, examination of the left shoulder showed normal ranges of motion. There was pain, tenderness and crepitus. The diagnoses were labral tear and AC joint osteoarthritis. The examiner opined that it was less likely than not that the current disability was incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that, while the Veteran had sustained a left shoulder strain in 2004, this appeared to be acute and transitory in nature. A causal connection between this acute strain and labral tears first noted in 2009 could not be made. Review of the record shows no complaint or manifestation of a left shoulder disorder during the Veteran's first two periods of service and a complaint of left shoulder strain in 2004. The only medical opinion in the record is that the strain was acute and transitory in nature such that it did not result in the chronic disorders that were first demonstrated in 2009, three years after the Veteran's last separation from service. As such, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left shoulder disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Achilles Tendonitis The Veteran contends that service connection should be established for Achilles tendonitis, which the Veteran asserts is related to his service-connected foot and ankle disabilities. Review of the record shows no complaint or manifestation of Achilles tendonitis during service or thereafter. Examination by VA in April 2016 showed that the Veteran did not manifest Achilles tendonitis. Whether service connection is claimed on direct, presumptive, or any other basis, a necessary element for establishing such a claim is the existence of a current disability. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997) (holding that section 1110 of the statute requires the existence of a present disability for VA compensation purposes); see also Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). The presence of a disability at the time of filing of a claim or during its pendency warrants a finding that the current disability requirement has been met, even if the disability resolves prior to the Board's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As there is no evidence of Achilles tendonitis in the record, the evidence is not sufficient to establish the presence of this disability during service or since his discharge from active duty. The Veteran has not submitted any evidence demonstrating a current diagnosis of Achilles tendonitis, nor has he submitted any medical or lay evidence describing symptomatology of this disorder. The current VA treatment records consistently show no complaints or findings with respect to the claimed Achilles tendonitis. As such, the evidentiary requirement of demonstrating a current diagnosis has not been satisfied and the claim must be denied. Rating Laws and Regulations Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) found in 38 C.F.R. Part 4. 38 U.S.C. § 1155. It is not expected that all cases will show all the findings specified; however, findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function will be expected in all instances. 38 C.F.R. § 4.21 (2017). 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 for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2017). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3 (2017). The United States Court of Appeals for Veterans Claims (Court) has held that "staged" ratings are appropriate for an increased rating claim where the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Lumbar Strain Service connection for lumbar strain was granted by the RO in a April 2007 rating decision. The 20 percent initial disability rating was awarded under the provisions of Code 5237 from the date following date of discharge in February 2006. An examination was conducted by VA in November 2005, prior to the Veteran's discharge from his most recent period of active duty. Examination of the thoracolumbar spine revealed no complaint of radiating pain on movement. There was no muscle spasm or tenderness noted. Straight leg raising was negative, bilaterally. There was no ankylosis of the spine. Range of motion of the spine was forward flexion to 60 degrees, with pain at 60 degrees. Extension, bilateral lateral flexion, and bilateral rotation were found to be normal. Motion was limited by pain after repetitive use, but there was no fatigue, weakness, lack of endurance, or incoordination following repetitive use. There were no signs of intervertebral disc syndrome (IVDS). X-ray studies of the lumbar spine were within normal limits. The diagnosis was chronic lumbar sprain. An examination was conducted by VA in March 2009. At that time, the Veteran had complaints of pain along the spine that was described as dull and aching. He reported severe flare-ups every two to three weeks that lasted hours. On physical examination there was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness. There was no muscle spasm, tenderness, or guarding severe enough to be responsible for an abnormal gait or abnormal spinal contour. Range of motion was forward flexion to 60 degrees, extension to 15 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 20 degrees. There were no additional limitations after three repetitions of range of motion. An examination was conducted by VA in April 2011. At that time, the Veteran complained of pain that occasionally radiated from the lumbar spine down his buttocks and the back of the lower extremities. (Service connection for neuropathy of the lower extremities has been established and is not part of the current appeal.) The Veteran did not describe incapacitating episodes of spine disease. Inspection of the spine was normal. Gait was antalgic. There was no thoracolumbar spine ankylosis. There was no spasm, atrophy, guarding, pain with motion, tenderness, or weakness. Range of motion was flexion to 60 degrees, extension to 10 degrees, bilateral lateral flexion to 15 degrees, and bilateral rotation to 20 degrees. There was objective evidence of pain on active range of motion. There were no additional limitations following repetitive motion. An MRI of the lumbar spine was unremarkable. The diagnosis was mild DJD of the lumbar spine with lumbar radicular symptoms. An examination was conducted by VA in April 2016. At that time, the thoracolumbar diagnoses were lumbosacral strain, degenerative arthritis of the spine and IVDS. The Veteran reported having constant pain and intermittent spasm, but did not report flare-ups. He reported functional loss on bending, lifting, or prolonged standing. Initial range of motion was forward flexion to 90 degrees, extension to 20 degrees, bilateral lateral flexion to 20 degrees, and bilateral lateral rotation to 20 degrees. There was evidence of pain with weight bearing and objective evidence of localized tenderness or pain on palpation of the joints. The Veteran was able to perform repetitive use testing with at least three repetitions without loss of function. There was no muscle spasm, but localized tenderness resulted in an abnormal gait and spinal contour. There was no guarding or muscle atrophy. There was no ankylosis of the spine and no evidence of IVDS. Imaging studies documented arthritis. Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (for Diagnostic Codes 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). Ratings under the General Rating Formula for Diseases and Injuries of the Spine are made with or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease. The General Rating Formula for Diseases and Injuries of the Spine provides a 20 percent disability rating is assigned for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent disability rating is assigned for forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The normal combined range of motion of the thoracolumbar spine is 240 degrees. See also Plate V, 38 C.F.R. § 4.71a. When rating degenerative arthritis of the spine (Diagnostic Code 5242), in addition to consideration of rating under the General Rating Formula for Diseases and Injuries of the Spine, rating for degenerative arthritis under Diagnostic Code 5003 should also be considered. 38 C.F.R. § 4.71a. Diagnostic Code 5243 provides that intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes provides a 20 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a. Note (1) to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Note (2) provides that, if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a. The Veteran's lumbar strain has consistently been rated at 20 percent throughout this appeal. For a schedular rating in excess of 20 percent certain criteria must be met. These include limitation of forward flexion to 30 degrees or less, demonstrated ankylosis of the spinal segment, or incapacitating episodes of IVDS having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Review of the record shows that the Veteran's forward flexion has been in excess of 30 degrees throughout the appeal. There has been no evidence of ankylosis and no complaints of incapacitating episodes of the duration or frequency that would meet the criteria for a rating in excess of 20 percent. As the Veteran has not met any of these criteria, a rating in excess of 20 percent is not warranted. Scar of the Vermilion Border of the Mid-Upper Lip Service connection for a scar of the vermilion border of the mid-upper lip was granted by the RO in a March 2009 rating decision. A noncompensable (0 percent) initial disability rating was awarded under the provisions of Code 7805 from the date of claim in 2008. The rating was increased to 30 percent by rating decision dated in September 2016, effective April 22, 2016, the date of a VA examination demonstrating an increased disability. The increase was under Code 7800. An examination was conducted by VA in March 2009. At that time, it was noted that the Veteran had sustained an upper lip laceration when struck by a rifle butt while on a training exercise. Examination showed a scar measuring 0.25 cm. by 1 cm. There was no tenderness to palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown, underlying tissue loss, elevation or depression of the scar, disfigurement, or induration or inflexibility. The diagnosis was scar of the vermillion border of the mid-upper lip. An examination was conducted by VA in June 2011. At that time, evaluation of the Veteran's scar showed no distortion or asymmetry in the facial scarring. An examination was conducted by VA on April 22, 2016. At that time, the scar of the upper lip was described as being on the left side with slight asymmetry, the left side being slightly thicker than the right by approximately 0.5 cm. The scar was not painful, or unstable. Disfigurement was described as having a noted "drooping" effect of the left lip over the teeth. A scar of the inner lip measuring 5 cm by 2 cm was also noted. This scar affected the surface contour that was depressed on palpation. Under Diagnostic Code 7800, a 10 percent evaluation is contemplated when there is one characteristic of disfigurement. A 30 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or, when there are two or three characteristics of disfigurement. A 50 percent evaluation is warranted when there is visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips; or, when there are four or five characteristics of disfigurement. An 80 percent evaluation is assigned when there is visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips); or, when there are six or more characteristics of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. There are eight characteristics of disfigurement for purposes of evaluation under § 4.118, as follows: Scar 5 or more inches (in.) (13 or more cm.) in length; scar at least one-quarter in. (0.6 cm.) wide at widest part; surface contour of scar elevated or depressed on palpation; scar adherent to underlying tissue; skin hypo-or hyper-pigmented in an area exceeding six square (sq.) in. (39 sq. cm.); skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six sq. in. (39 sq. cm.); underlying soft tissue missing in an area exceeding six sq. in. (39 sq. cm.); and, skin indurated and inflexible in an area exceeding six sq. in. (39 sq. cm.). Id. at Note I. Regarding the scar of the Veteran's lip, the RO determined that, in April 2016, the scar exhibited two characteristics of disfigurement, a drooping effect and elevation or depression of the tissue. Therefore, the RO assigned an evaluation of 30 percent under Diagnostic Code 7800 beginning on April 22, 2016. Prior to that date, the record showed only that the Veteran had scarring of the lip that was without tenderness to palpation, adherence to underlying tissue, limitation of motion or loss of function, underlying soft tissue damage, skin ulceration or breakdown, underlying tissue loss, elevation or depression of the scar, disfigurement, or duration or inflexibility. As such, there is no basis for the assignment of a compensable evaluation prior to the findings of the April 22, 2016, examination. The Board agrees that a 30 percent rating is warranted as of April 22, 2016, but does not find that this level of disability has been demonstrated at any time prior to that date. The 2009 VA examiner indicated that the scars were well healed and measured 0.5 cm by 1 cm. The examination specifically found no disfigurement, depression or elevation. Similarly, the "drooping" noted on VA examination in April 2016 was not described prior to that date. As such, there is no basis for a compensable rating for the scar of the mid-upper lip prior to April 22, 2016. A rating in excess of 30 percent from April 22, 2016, is similarly not warranted because the evidence does not show visible or palpable tissue loss, or either gross distortion or asymmetry of two features or paired sets of features or four or five characteristics of disfigurement. As such, the Board finds that a rating in excess of 30 percent for a scar of the vermillion boarder of the mid-upper lip is not warranted from that date. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for increased initial ratings for a scar of the vermillion border of the mid-upper lip, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. Scar of the Abdominal Area Service connection for a scar of the abdominal area was granted by the RO in a March 2006 rating decision. A noncompensable (0 percent) initial disability rating was awarded under the provisions of Code 7805 from the date following discharge from service. The rating was increased to 10 percent by rating decision dated in September 2016, effective April 22, 2016, the date of a VA examination demonstrating an increased disability. The increase was under Code 7804. The Board notes that as of October 23, 2008, revised provisions for evaluating scars were enacted; however, this new regulation indicates that the revised provisions are applicable only to claims received on or after October 23, 2008. Accordingly, these revisions do not apply to the present case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Rather, the Veteran's claim for a higher rating for scars will be considered solely under the criteria effective as of the date of the claim, which is effectively the day following the day of his discharge from active duty. Under Code 7801, scars, other than of the head, face or neck, that are deep or that cause limited motion warrant a 10 percent rating when the scars cover an area or areas exceeding 6 square inches (39 sq. cm.). Scars that are superficial, do not cause limited motion, and cover an area of 144 square inches or more are given a compensable rating under Code 7802. Unstable superficial scars are rated under Code 7803. An unstable scar is one where, for any reason, there is frequent loss of covering of the skin over the scar. Superficial scars that are painful on examination are rated under Code 7804. Code 7804 stipulates that a 10 percent disability evaluation will be warranted with evidence that a superficial service-connected scar is painful on examination. Code 7805 provides that other scars are rated on limitation of function of the affected part. A deep scar is one associated with underlying soft tissue damage, and a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, DCs 7801-7805. Disfigurement of the head, face, or neck: With visible or palpable tissue loss and either gross distortion or asymmetry of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement, an 80 percent evaluation is warranted; with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement, a 50 percent evaluation is warranted; with visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement, a 30 percent evaluation is warranted; and with one characteristic of disfigurement a 10 percent evaluation is warranted. Note (1): The 8 characteristics of disfigurement, for purposes of evaluation under Sec. 4.118, are: Scar 5 or more inches (13 or more cm.) in length. Scar at least one-quarter inch (0.6 cm.) wide at widest part. Surface contour of scar elevated or depressed on palpation. Scar adherent to underlying tissue. Skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.). Skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.). Underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.). Skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Scars, other than head, face, or neck, that are deep or that cause limited motion: area or areas exceeding 144 square inches (929 sq.cm.), warrants a 40 evaluation; area or areas exceeding 72 square inches (465 sq. cm.), warrants a 30 evaluation; area or areas exceeding 12 square inches (77 sq. cm.), warrants a 20 evaluation; and area or areas exceeding 6 square inches (39 sq. cm.), warrants a 10 percent evaluation. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with Sec. 4.25 of this part. Note (2): A deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7801 Scars, other than head, face, or neck, that are superficial and that do not cause limited motion: Area or areas of 144 square inches (929 sq. cm.) or greater, a 10 percent evaluation is warranted. Note (1): Scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of extremities or trunk, will be separately rated and combined in accordance with Sec. 4.25 of this part. Note (2): A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7802. Scars, that are superficial or unstable, warrant a 10 percent evaluation. Note (1): An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2): A superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Code 7803. Scars, that are superficial and painful on examination, warrant a 10 percent evaluation. Note (1): A superficial scar is one not associated with underlying soft tissue damage. Note (2): In this case, a 10-percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation. 38 C.F.R. § 4.118, Code 7804. Scars, other; are rated on limitation of function of the affected part. 38 C.F.R. § 4.118, Code 7805. An examination was conducted for VA in November 2005, prior to the Veteran's discharge from active duty. At that time, there was a scar located on the lower abdominal area that measured about 2.0 cm by 0.1 cm. There was no tenderness, disfigurement, ulceration, adherence, instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, or abnormal texture. There was also a scar located at the umbilicus that was level and measured about 0.5 cm by 0.1 cm. There was no tenderness, disfigurement, ulceration, adherence instability, tissue loss, keloid formation, hypopigmentation, hyperpigmentation, or abnormal texture. An examination was conducted by VA on March 5, 2009. At that time, a laparoscopic inguinal hernia repair scar and several small surgical scars on the abdomen in the peri-umbilical region were noted. These were said to measure less than 1 cm. The examiner indicated that the Veteran had pain of the scarring, but did not specifically indicate that it was the abdominal scar that was painful. An examination was conducted by VA on June 25, 2011. At that time, examination showed a scar of the anterior surface of the trunk in the inguinal area. There was no skin breakdown over the scar and no report of pain. The scar measured 1 cm by 6 cm, with an area of less than 6 square inches. The scar was not painful, with no sign of skin breakdown, no edema, no keloid formation, and no other disabling effects. The diagnosis was surgical scar. An examination was conducted by VA on April 22, 2016. At that time the pertinent diagnosis was of an umbilical keloid scar, status post hernia repair. There were two scars that were painful, with a dull aching pain without touch. There were also intermittent sharp pains to touch. There was no frequent loss of covering of the skin over the scars. They were not unstable. Total area was 1 cm2. Prior to March 5, 2009, the record showed only that the Veteran had asymptomatic scarring of his abdomen as a result of surgery. On that date, there was an indication that this scarring was painful. While this was a somewhat equivocal finding in that there could be other interpretations, resolving reasonable doubt in the Veteran's favor it is found that the abdominal scarring was painful at that time. Therefore, a 10 percent evaluation was warranted. On examination on June 25, 2011, however, it was specifically noted that there was no pain of the abdominal scarring. As such, the compensable evaluation would no longer be warranted from that date. On April 22, 2016, the scar was again noted to be painful. Based upon this finding a 10 percent rating was established by the RO. The record does not disclose any basis upon which a rating in excess of 10 percent may be established. In this regard, it is noted that there is no indication that the scars are unstable or measure in excess of 12 square inches. Neither is there evidence of underlying tissue damage or that there is frequent loss of covering of skin over the scars. Under these circumstances, the Board finds that a 10 percent rating is warranted for the abdominal scarring from March 5, 2009, to June 24, 2011, but that from June 25, 2011 to April 21, 2016, improvement is demonstrated and the rating should be returned to noncompensable. A 10 percent rating, but no more, is again warranted from April 22, 2016. To this extent, the appeal is granted. Right Knee Disability Service connection for patellofemoral pain syndrome of the right knee was granted by the RO in an April 2007 rating decision. The current 10 percent rating was assigned at that time under Code 5260, based on functional loss. An examination was conducted by VA in November 2005. At that time, the Veteran complained of pain in the right knee. Range of motion of the right knee was from 140 degrees flexion to 0 degrees extension. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Testing for instability was within normal limits. X-ray studies of the right knee were reported to be normal, but a review of a study dated in November 2005 showed bilateral tri-compartmental osteoarthritis of a minimal degree. An examination was conducted by VA in March 2009. At that time, the Veteran's right knee disorder was described. It was noted that he had undergone periodic steroid injections. Joint symptoms included instability, pain, and stiffness. The Veteran was able to stand for up to one hour and walk one to three miles. He walked with an antalgic gait. Examination showed crepitus. Range of motion was from 0 degrees extension to 140 degrees flexion. There was no evidence of functional impairment after repetitions of motion. X-ray studies were reportedly normal. An examination was conducted by VA in April 2014. At that time, the diagnosis was patellofemoral syndrome of the right knee. Range of motion was from 0 degrees extension to 75 degrees flexion. There was no objective evidence of painful motion. The Veteran was able to perform repetitive use testing without additional limitation of motion or functional loss. Joint stability testing was normal. Imaging studies reportedly showed degenerative or traumatic arthritis. An examination was conducted by VA in April 2015. At that time, the diagnosis was patellofemoral syndrome of the right knee. Range of motion was from 0 degrees extension to 85 degrees flexion. There was evidence of pain on weight bearing. There was evidence of pain on weight bearing. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss. There was no muscle atrophy or ankylosis. There was no subluxation or lateral instability, but there was evidence of recurrent effusion. An examination was conducted by VA in December 2015. At that time, the pertinent diagnosis was DJD of the right knee. The Veteran reported pain in the knee that worsened with prolonged standing. Range of motion was from 0 degrees extension to 85 degrees flexion. Pain was noted on examination, but did not result in additional functional loss. There was no muscle atrophy and no ankylosis. There was no history of recurrent subluxation or lateral instability and no effusion. Joint stability testing showed no instability. There was no evidence of a meniscus condition. An examination was conducted by VA in October 2016. At that time, the diagnosis was patellofemoral pain syndrome of the right knee. Range of motion of the right knee was from 0 degrees extension to 75 degrees flexion. There was evidence of pain on weight bearing. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or additional limitation of motion. There was no muscle atrophy or ankylosis and no history of recurrent subluxation or lateral instability and no effusion. Joint stability testing showed no instability. There was no evidence of a meniscus condition. Normal ranges of motion of the knee are to 0 degrees in extension, and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5003 provides that degenerative arthritis that is 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. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, Diagnostic Code 5003 provides a 20 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 pct and 10 pct ratings based on X-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on X-ray findings, above, will not be utilized in rating conditions listed under Diagnostic Codes 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, Diagnostic Code 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Separate disability ratings are possible for arthritis with limitation of motion under Diagnostic Codes 5003 and instability of a knee under Diagnostic Code 5257. See VAOPGCPREC 23-97. When x-ray findings of arthritis are present and a veteran's knee disability is rated under Diagnostic Code 5257, the veteran would be entitled to a separate compensable rating under Diagnostic Code 5003 if the arthritis results in noncompensable limitation of motion and/or objective findings or indicators of pain. See VAOPGCPREC 9-98. Diagnostic Code 5256 provides ratings for ankylosis of the knee. Favorable ankylosis of the knee, with angle in full extension, or in slight flexion between zero degrees and 10 degrees, is rated 30 percent disabling. Unfavorable ankylosis of the knee, in flexion between 10 degrees and 20 degrees, is to be rated 40 percent disabling; unfavorable ankylosis of the knee, in flexion between 20 degrees and 45 degrees, is rated 50 percent disabling; and extremely unfavorable ankylosis, in flexion at an angle of 45 degrees or more, is rated 60 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5257 provides ratings for other impairment of the knee that includes recurrent subluxation or lateral instability. Slight recurrent subluxation or lateral instability of the knee is rated 10 percent disabling; moderate recurrent subluxation or lateral instability of the knee is rated 20 percent disabling; and severe recurrent subluxation or lateral instability of the knee is rated 30 percent disabling. 38 C.F.R. § 4.71a. Diagnostic Code 5258 provides a 20 percent rating for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a. Diagnostic Code 5259 provides a 10 percent rating for removal of semilunar cartilage that is symptomatic. 38 C.F.R. § 4.71a. Diagnostic Code 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensably (0 percent) disabling; flexion of the leg limited to 45 degrees is rated 10 percent disabling; flexion of the leg limited to 30 degrees is rated 20 percent disabling; and flexion of the leg limited to 15 degrees is rated 30 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensably (0 percent) disabling; extension of the leg limited to 10 degrees is rated 10 percent disabling; extension of the leg limited to 15 degrees is rated 20 percent disabling; extension of the leg limited to 20 degrees is rated 30 percent disabling; extension of the leg limited to 30 degrees is rated 40 percent disabling; and extension of the leg limited to 45 degrees is rated 50 percent disabling. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) of the same knee joint). Diagnostic Code 5262 provides ratings based on impairment of the tibia and fibula. Malunion of the tibia and fibula with slight knee or ankle disability is rated 10 percent disabling; malunion of the tibia and fibula with moderate knee or ankle disability is rated 20 percent disabling; and malunion of the tibia and fibula with marked knee or ankle disability is rated 30 percent disabling. Nonunion of the tibia and fibula with loose motion, requiring a brace, is rated 40 percent disabling. 38 C.F.R. § 4.71a. The Veteran's right knee disorder is shown to be manifested by DJD without significant limitation of motion until the examination report in April 2014 when limitation of flexion to 75 degrees was noted. For a rating in excess of 10 percent, limitation of flexion to 30 degrees would have to be demonstrated. Additional ratings could be awarded under limitation of extension or other impairment of the knee such as repeated subluxation or lateral instability, but none of the examinations in the record demonstrated such additional disability. In view of this, the Board can find no basis for a rating in excess of the 10 percent that was initially assigned when service connection was established. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for an increased initial rating for a right knee disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Left Knee Disability Service connection for osteoarthritis of the left knee was granted by the RO in an October 2014 rating decision. A 10 percent rating was initially assigned at that time under Codes 5260 and 5003. In a September 2016 rating decision, the RO granted an effective date for arthritis of the left knee retroactive to the date following the Veteran's discharge from service, rated noncompensable until March 4, 2009, following which a 10 percent rating was assigned. An examination was conducted by VA in November 2005. At that time, the Veteran complained of pain, stiffness, and numbness when kneeling. Range of motion of the left knee was from 140 degrees flexion to 0 degrees extension. Joint function was not additionally limited by pain, fatigue, weakness, lack of endurance, or incoordination after repetitive use. Testing for instability was within normal limits. X-ray studies of the left knee were reported to be normal, but a review of a study dated in November 2005 showed bilateral tri-compartmental osteoarthritis of a minimal degree. An examination was conducted by VA in March 2009. At that time, the Veteran's left knee disorder was described. The Veteran was able to stand for up to one hour and walk one to three miles. He walked with an antalgic gait. Examination showed crepitus. Range of motion was from 0 degrees extension to 140 degrees flexion. There was no evidence of functional impairment after repetitions of motion. X-ray studies were reportedly normal. An examination was conducted by VA in April 2014. At that time, the diagnosis was osteoarthritis of the left knee. Range of motion was from 0 degrees extension to 75 degrees flexion. There was no objective evidence of painful motion. The Veteran was able to perform repetitive use testing without additional limitation of motion or functional loss. Joint stability testing was normal. Imaging studies reportedly showed degenerative or traumatic arthritis. An examination was conducted by VA in April 2015. At that time, the diagnoses included patellofemoral syndrome and degenerative arthritis of the left knee. Range of motion was from 0 degrees extension to 80 degrees flexion. There was evidence of pain on weight bearing. There was no evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss. There was no muscle atrophy or ankylosis. There was no subluxation or lateral instability, but there was evidence of recurrent effusion. An examination was conducted by VA in December 2015. At that time, the pertinent diagnosis was DJD of the left knee. The Veteran reported pain in the knee that worsened with prolonged standing. Range of motion was from 0 degrees extension to 85 degrees flexion. Pain was noted on examination, but did not result in additional functional loss. There was no muscle atrophy and no ankylosis. There was no history of recurrent subluxation or lateral instability and no effusion. Joint stability testing showed no instability. There was a report of an arthroscopic procedure performed in 1982. An examination was conducted by VA in October 2016. At that time, the diagnosis was degenerative arthritis of the left knee. Range of motion of the left knee was from 0 degrees extension to 75 degrees flexion. There was evidence of pain on weight bearing. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing without additional functional loss or additional limitation of motion. There was no muscle atrophy or ankylosis and no history of recurrent subluxation or lateral instability and no effusion. Joint stability testing showed no instability. The Veteran's left knee disorder is shown to be manifested by DJD without significant limitation of motion until the examination report in April 2014 when limitation of flexion to 75 degrees was noted. While the Veteran was not rated as 10 percent until March 1990 when crepitus was noted, the Board finds that the symptoms noted on examination in November 2005 prior to discharge from service were similar to those of the right knee, primarily pain in the knee joint, for which a 10 percent rating was awarded based on functional loss. In November 2005, there was radiographic evidence of minimal osteoarthritis and the Veteran complained of pain, stiffness and numbness when kneeling. As such, the Board finds that the 10 percent rating that was made effective in March 2009 should be retroactively awarded to the effective date of service connection, the day following the date of the Veteran's discharge from active duty. For a rating in excess of 10 percent, limitation of flexion to 30 degrees would have to be demonstrated. Additional ratings could be awarded under limitation of extension or other impairment of the knee such as recurrent subluxation or lateral instability, but none of the examinations in the record demonstrated such additional disability. In view of this, the Board can find no basis for a rating in excess of 10 percent. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for a left knee disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. §§ 4.3, 4.7. ORDER Service connection for a right shoulder disorder is denied. Service connection for a left shoulder disorder is denied. Service connection for bilateral Achilles tendonitis is denied. An initial rating in excess of 20 percent for lumbar strain is denied. An initial rating for a scar of the vermilion border of the mid-upper lip, rated noncompensable prior to April 22, 2016, and 30 percent from April 22, 2016 is denied. An initial rating for a scar of the abdominal area, rated noncompensable prior to March 5, 2009 is denied; the rating is increased to 10 percent from March 5, 2009 until June 24, 2011, following which the rating is reduced to noncompensable; a rating of 10 percent, but no higher, is warranted from April 22, 2016. The appeal is granted to this extent, subject to the controlling regulations governing the payment of monetary benefits. An increased rating for osteoarthritis of the right knee with patellofemoral syndrome, rated 10 percent disabling, is denied. An initial rating of 10 percent, but no higher, for osteoarthritis of the left knee with patellofemoral syndrome is warranted from the effective date of the award of service connection on February 3, 2006 to March 4, 2009. To this extent, the appeal is granted, subject to the controlling regulations governing the payment of monetary benefits. An initial rating in excess of 10 percent from March 5, 2009, for osteoarthritis of the left knee with patellofemoral syndrome is denied. REMAND The remaining issue that was remanded the Board in July 2015 involved an increased rating for PFB. The Veteran contended that this disorder had affected his head and scalp and the issue was remanded for development of this issue. In response to the remand, the RO developed the issue of service connection for PFB of the scalp. This was denied on the basis that the Veteran was already service connected for PFB and that additional service connection would constitute pyramiding under 38 C.F.R. § 4.14 (2017). This does not, however, develop the matter of an increased rating for PFB that was remanded by the Board. As such, the matter must be returned for appropriate development. Accordingly, the case is REMANDED for the following action: The Veteran and his representative must be provided a Statement of the Case on the issue of entitlement to an increased rating for PFB. If and only if, the Veteran files a timely substantive appeal should this issue be returned to the Board. See 38 C.F.R. § 19.29; Manlincon v. West, 12 Vet. App. 238 (1999). The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs