Citation Nr: 1808354 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 12-05 042A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for right wrist arthritis. 2. Entitlement to service connection for left wrist arthritis. 3. Entitlement to service connection for right carpal tunnel syndrome (CTS). 4. Entitlement to service connection for left CTS. 5. Entitlement to service connection for a respiratory condition, claimed as difficulty breathing. 6. Entitlement to service connection for right lower extremity (RLE) radiculopathy. 7. Entitlement to service connection for left lower extremity (LLE) radiculopathy. 8. Entitlement to service connection for bilateral hearing loss. 9. Entitlement to an initial disability rating in excess of 10 percent for the service-connected right knee osteoarthritis. 10. Entitlement to an initial disability rating in excess of 10 percent for the service-connected left knee osteoarthritis. 11. Entitlement to an initial disability rating in excess of 10 percent for the service-connected irritable bowel syndrome (IBS). REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD L. B. Cryan, Counsel INTRODUCTION The Veteran served on active duty from July 1983 to September 1991 and from December 1995 to November 2008. This case is before the Board of Veterans' Appeals (Board) on appeal from April 2009 and December 2011 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In the April 2009 rating decision, the RO, in pertinent part, granted service connection for right and left knee osteoarthritis, and assigned an initial 10 percent rating for the right knee and a noncompensable rating for the left knee, effective from December 1, 2008. Additionally, the RO granted service connection for hypertension, migraines, obstructive sleep apnea (OSA), degenerative disc disease (DDD) of the lumbar spine, DDD of the cervical spine; and, assigned initial noncompensable ratings for those disabilities, effective from December 1, 2008. The rating decision also denied, in pertinent part, service connection for left and right CTS, left and right wrist arthritis, difficulty breathing, fatty liver, IBS, left and right lower extremity radiculopathy, and bilateral hearing loss. In his March 2010 Notice of Disagreement (NOD), the Veteran disagreed with the above service connection denials, as well as the initial ratings assigned for the grants of service connection listed above. In a December 2011 Decision Review Officer (DRO) rating decision, the RO granted increased initial ratings of 50 percent for the OSA, 30 percent for the migraines, and 10 percent each for the hypertension, DDD of the lumbar spine, DDD of the cervical spine, and left knee osteoarthritis. All of these increased ratings are effective from December 1, 2008, the effective date of service connection. As these ratings do not constitute complete grants of the benefits sought on appeal, the claims for higher initial ratings for these disabilities remained in appellate status, and were subsequently addressed in a December 2011 Statement of the Case (SOC). In addition to the above, the December 2011 rating decision also granted service connection for IBS and assigned an initial 10 percent rating, effective from December 1, 2008. The grant of service connection is considered a complete grant of benefits sought on appeal, and therefore, the issue was not included in the December 2011 SOC. However, a March 2012 NOD, prepared by the Veteran's representative, indicates that the Veteran disagreed with the initial rating assigned for the service-connected IBS. In addition, the March 2012 NOD also reflects that the Veteran continued his disagreement with the ratings assigned for the right and left knee arthritis, and the denial of service connection for bilateral wrist CTS and arthritis, difficulty breathing, bilateral lower extremity radiculopathy, and bilateral hearing loss. No other issues were listed. Attached to the March 2012 NOD letter was the Veteran's timely VA Form 9, substantive appeal to the Board. The Form 9 reflects that the Veteran checked Box "B" indicating that he had read the SOC and that he only wished to appeal the issues listed on the attached March 2012 NOD letter. Accordingly, the only issues currently on appeal are those listed on the front page of this decision. The Veteran's VA Form 9 also reflects his request for a Board hearing at VA's Central Office in Washington, D.C. The hearing was initially scheduled for October 2016; however, the Veteran requested to reschedule the hearing. See October 2016 and December 2016 correspondence. According to an August 2017 letter from the Board, the Veteran was notified that his hearing was subsequently rescheduled for September 2017; however, the Veteran failed to report to the hearing and has not provided cause for his failure to report. Accordingly, his hearing request is deemed withdrawn. The issue(s) of entitlement to an initial disability rating in excess of 10 percent for the service-connected IBS is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran does not have x-ray evidence of right or left wrist arthritis. 2. The Veteran has right wrist symptoms that had their onset during service, and which more nearly approximate a diagnosis of right wrist CTS. 3. The Veteran has left wrist symptoms that had their onset during service, and which more nearly approximate a diagnosis of left wrist CTS. 4. The Veteran does not have a diagnosis of a chronic respiratory disorder manifested by breathing problems. 5. The Veteran has right lower extremity symptoms that had their onset during service, and which more nearly approximate a diagnosis of right lower extremity radiculopathy associated with the service-connected lumbar spine disability. 6. The Veteran has left lower extremity symptoms that had their onset during service, and which more nearly approximate a diagnosis of left lower extremity radiculopathy associated with the service-connected lumbar spine disability. 7. The Veteran does not have a hearing loss disability for VA purposes. 8. The Veteran's right and left knee osteoarthritis is manifested by flexion limited to no more than 90 degrees with consideration of pain on motion, extension normal; and, with symptoms that more nearly approximate mild instability, bilaterally. CONCLUSIONS OF LAW 1. The criteria for service connection for right wrist arthritis have not been met or approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307,3.309 (2017). 2. The criteria for service connection for left wrist arthritis have not been met or approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307,3.309 (2017). 3. The criteria for service connection for right wrist CTS have been more nearly approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. The criteria for service connection for left wrist CTS have been more nearly approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 5. The criteria for service connection for a respiratory/breathing disorder have not been met or approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 6. The criteria for service connection for right lower extremity radiculopathy have been more nearly approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 7. The criteria for service connection for left lower extremity radiculopathy have been more nearly approximated. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 8. The criteria for service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.385 (2017). 9. The criteria for a disability rating in excess of 10 percent for the service-connected osteoarthritis of the right knee have not been met or approximated at any time covered by this claim. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2017). 10. The criteria for a separate 10 percent rating, but not higher, for mild instability of the right knee have been more nearly approximated since the effective date of service connection. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2017). 11. The criteria for a disability rating in excess of 10 percent for the service-connected osteoarthritis of the left knee have not been met or approximated at any time covered by this claim. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2017). 12. The criteria for a separate 10 percent rating, but not higher, for mild instability of the left knee have been more nearly approximated since the effective date of service connection. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 4.3, 4.7, 4.40, 4.59, 4.71a, Diagnostic Codes 5003, 5010, 5257, 5260, 5261 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In this case, the Veteran filed his initial claims in September 2008, approximately two months prior to his active duty discharge, as part of the VA Benefits Delivery at Discharge (BDD) program. In response, the RO sent the Veteran a notice letter to the Veteran in September 2008. The letter satisfies VA notice requirements. 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). The Board is satisfied that VA has made reasonable efforts to obtain relevant records and evidence. The Veteran's service treatment records (STRs), personnel records, and VA treatment records have been associated with the record. The Veteran was afforded an opportunity to provide testimony at a hearing. In September 2008, the Veteran responded to the notice letter acknowledging receipt of proper notice, and indicating that he had no other information or evidence to give to VA to substantiate his claims. In sum, the Board is satisfied that the originating agency properly processed the Veteran's claims after providing the required notice and that any procedural errors in the development and consideration of the claims by the originating agency were insignificant and non-prejudicial to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Finally, in September 2017, the Veteran submitted additional medical evidence to support his claims, along with a waiver of review by the AOJ in the first instance. The evidence has been associated with the claims file and has been reviewed. Accordingly, the Board may proceed without prejudice. II. Service Connection The Veteran seeks service connection for right and left wrist CTS, right and left wrist arthritis, bilateral lower extremity radiculopathy, a breathing/respiratory disorder, and bilateral hearing loss. Service connection may be established for a disability resulting from personal injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to establish service connection, there must be lay or medical evidence of (1) a current disability, (2) incurrence or aggravation of a disease or injury in service, and (3) a nexus between the in-service injury or disease and the current disability. See 38 U.S.C. § 1110; Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed .Cir.2009); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed.Cir.2004); 38 C.F.R. § 3.303. Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Moreover, where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and a chronic disorder such as migraine headaches or a psychosis, for example, becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such diseases during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The credibility and weight of all the evidence, including the medical evidence, should be assessed to determine its probative value, and the evidence found to be persuasive or unpersuasive should be accounted for, and reasons should be provided for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt is meant one which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. Wrists The Veteran's STRs show that the Veteran broke his left wrist several years prior to entry into active duty. His entrance examination indicates that there were no complications, no pins, and no screws associated with the fracture, and the left wrist examination at the time of entry was normal with no fracture sequelae. The service treatment records (STRs) further show reports of pain and numbness about both wrists. He was diagnosed with CTS and underwent physical therapy for CTS in July 2008. The initial physical therapy assessment notes that the Veteran was diagnosed with bilateral CTS, and presented with increased pain and decreased strength of both wrists, with a motor examination indicating 4/5 bilaterally. A July 2008 MRI of the left wrist, however, noted only a very small cyst of little significance, and no evidence of median nerve abnormality or soft tissue abnormality. Nevertheless, because the Veteran's wrists remained painful and weak, the Veteran continued with physical therapy in August 2008 and September 2008, with a diagnosis of bilateral CTS. The Veteran reported at an October 2008 VA examination that his wrists are painful at the dorsal aspect. The pain is dull and intermittent, worse with activity. The Veteran also reports that his left fourth and fifth digits tingle, and he has numbness in all 10 fingers. October 2008 bilateral hand x-rays were unremarkable, and there is no x-ray evidence to the contrary. As there is no evidence of arthritis of either wrist, service connection for arthritis of the right and left wrists is not warranted. However, the Veteran has a diagnosis of bilateral CTS, was treated for bilateral wrist pain from June 2008 through September 2008, and continued to report wrist pain on his pre-discharge examination, and at his October 2008 VA examination. The October 2008 VA examiner found the Veteran's bilateral wrist examination essentially negative, but that finding was based on observation of the wrists and negative x-ray evidence of arthritis. The examiner did not opine as to the cause of the Veteran's wrist pain, which the Board finds credible, and which was previously attributed to CTS. In summary, the evidence for and against service connection for bilateral CTS is in equipoise; that is, the evidence demonstrating that the Veteran has a diagnosis of CTS is equally weighted against the evidence demonstrating other etiology. Moreover, the record clearly establishes that the Veteran had an onset of bilateral wrist pain and weakness during service, with a diagnosis of CTS, and without x-ray evidence of arthritis, and that same pain has continued since service. As no other potential cause of the Veteran's wrist pain has been provided, the Board must resolve all doubt and find that the Veteran's symptoms more nearly approximate that of CTS. Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that it is at least as likely as not that the Veteran has a diagnosis of right and left wrist CTS that had its onset during service. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for bilateral CTS. Lower Extremity Radiculopathy The STRs show that the Veteran complained of back pain with radiation to the left leg in July 2003. In April 2008, the Veteran reported pain shooting down the right leg, and believed that he had nerve damage and a left sciatic nerve condition. A June 2008 lumbar spine MRI confirmed degenerative disc disease at L5-S1, with disc protrusion and small annular tear at the L5-S1 level. Bilateral lumbar radiculopathy was diagnosed in June 2008. Significantly, the examiner specifically indicated there was no sensory deficit bilaterally; however, the examiner nevertheless diagnosed bilateral lower extremity radiculopathy based on the Veteran's reported symptoms of pain, and the objective findings on the June 2008 MRI. At the pre-discharge VA examination in October 2008, the Veteran reported the same symptoms; however the examiner did not diagnose radiculopathy, because motor, reflex, and sensory exams were normal. However, the evidence establishes that the Veteran reported shooting pains down his legs, similar to what is described as sciatic nerve-type pain, and a medical professional diagnosed bilateral lower extremity radiculopathy based on those reports of pain, as well as findings on MRI of the lumbar spine. Although the October 2008 VA examiner essentially disregarded the Veteran's reports of pain, the Board finds that the evidence of record shows that the Veteran, as likely as not, experienced an onset of bilateral lower extremity radiculopathy in service, which has continued to the present time. The Veteran is competent to report an observable symptoms such as pain, and there is no reason to doubt his credibility in that regard. Therefore, resolving reasonable doubt in the Veteran's favor, the Board finds that it is at least as likely as not that the Veteran has a diagnosis of bilateral lower extremity radiculopathy that had its onset during service. The Veteran is therefore entitled to the benefit of the doubt. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for bilateral lower extremity radiculopathy associated with the service-connected lumbar spine degenerative disc disease. Respiratory/Breathing The Veteran's STRs show that he reported difficulty breathing and shortness of breath which was exercise-induced. The Veteran underwent a workup during service, but no disability was identified. The Veteran reported to an October 2008 VA examiner that he continues to have shortness of breath after running, but has no trouble walking long distances, and denied current symptoms of chronic cough, wheezing and hemoptysis. He reported using a nasal spray for allergies, but was never prescribed any type of lung inhaler. A chest x-ray was negative, and pulmonary function testing (PFT) revealed normal spirometry. In summary, the evidence of record does not support a finding of a current chronic respiratory disability in service, and the Veteran has not provided any evidence to contradict that finding. Thus, while the Veteran exhibits shortness of breath with exertion, at no time during service, or since, has the competent medical evidence of record indicated that the Veteran has an abnormal breathing disorder chronic in nature. Accordingly, there is no current disability and therefore service connection for difficulty breathing is not warranted. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992); Gilpin v. Brown, 155 F.3d 1353 (Fed. Cir. 1998) [service connection may not be granted unless a current disability exists]. Under 38 U.S.C.A. § 1110, it is essential that there be a current disability in order to establish service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Absent proof of a current disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Hearing Loss There are specific requirements regarding what constitutes a hearing loss disability under VA law. Generally, the threshold for normal hearing is from 0 to 20 decibels. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). For the purpose of applying the laws administered by VA, impaired hearing is considered to be a disability when the auditory threshold at any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater, or when speech recognition scores utilizing the Maryland CNC Tests are less than 94 percent. 38 C.F.R. § 3.385. Thus, even if some degree of hearing loss is shown at various frequencies (i.e. a puretone threshold above 20 at any frequency between 500 Hz and 4000 Hz) such findings do not necessarily reflect a defect with regard to hearing. See McKinney v. McDonald, 28 Vet. App. 15, 29 (2016) (holding that hearing loss that does not meet the requirements of § 3.385 is not a "defect" because it is not considered a disability for VA purposes). Even though disabling hearing loss is not demonstrated at separation, a veteran may, nevertheless, establish service connection for a current hearing disability by submitting evidence that a current disability is related to service. Hensley v. Brown, 5 Vet. App. 155 (1993). The Veteran reported on his April 2008 pre-discharge examination that he noticed a hearing loss bilaterally. However, the Veteran's June 2008 audiogram was normal, with puretone thresholds in decibels, in the right ear of 0, 5, 0, 0, -5 at 500, 1000, 2000, 3000, and 4000 Hz respectively; and, in the left ear of -10, 5, 0-5, 0, 5, at 500, 1000, 2000, 3000, and 4000 Hz respectively. Likewise, all prior in-service audiograms showed similar findings, and no significant threshold shift during service is shown. See, e.g. November 1984, May 1986, May 1987, February 1991, and March 1995 audiograms. An October 2008 pre-discharge VA audio examination likewise did not reveal a hearing loss disability for VA purposes. The puretone thresholds, in decibels, were as follows: Right Ear: 10 at 500 Hz, 5 at 1000 Hz, 10 at 2000 Hz, 20 at 3000 Hz. and 20 at 4000 Hz. Left Ear: 10 at 500 Hz, 5 at 1000 Hz, 10 at 2000 Hz, 25 at 3000 Hz and 15 at 4000 Hz. The speech recognition score using the Maryland CNC word list was 94 percent in the right ear and 96 percent in the left ear. Thus, while the objective findings show that the Veteran's hearing declined between April 2008 and October 2008, and that impaired hearing is noted at 3000 Hz, the findings from the October 2008 audio evaluation do not rise to the level of a hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. There is no medical evidence to the contrary. Accordingly, as the evidence of record does not provide a current diagnosis of a bilateral hearing loss disability for VA purposes, service connection for bilateral hearing loss is not warranted. III. Increased Rating The Veteran seeks initial disability ratings in excess of 10 percent for the right and left knee osteoarthritis. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The percentage ratings are based on the average impairment of earning capacity as a result of a service-connected disability, and separate diagnostic codes identify the various disabilities and the criteria for specific ratings. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. If two disability evaluations are potentially applicable, the higher evaluation 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. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Staged ratings must be considered, which are appropriate when the evidence establishes that the claimed disability manifested symptoms that would warrant different ratings for distinct time periods during the appeal. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). See also Fenderson v. West, 12 Vet. App. 119, 126 (1999) (applying this concept to initial ratings). The Veteran's right and left knee arthritis is rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5010 for traumatic arthritis. Traumatic arthritis is to be rated as degenerative arthritis under Diagnostic Code 5003. Pursuant to Diagnostic Code 5003, arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic code(s) for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, x-ray evidence of involvement of 2 or more major joints or two or more minor joint groups, with occasional incapacitating exacerbations warrants a 20 percent evaluation. X-ray evidence of involvement of 2 or more major joints or 2 or more minor joints warrants a 10 percent evaluation. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knee joint is considered a major joint. 38 C.F.R. § 4.45. Normal range of motion for the knee is defined as follows: flexion to 140 degrees and extension to 0 degrees. See 38 C.F.R. § 4.71, Plate II. Under Diagnostic Code 5260, limitation of flexion of the leg provides a non-compensable rating if flexion is limited to 60 degrees, a 10 percent rating where flexion is limited to 45 degrees, a 20 percent rating where flexion is limited to 30 degrees, and a maximum 30 percent rating if flexion is limited to 15 degrees. 38 C.F.R. § 4.71a. Under Diagnostic Code 5261, limitation of extension of the leg provides a non-compensable rating if extension is limited to five degrees, a 10 percent rating if limited to 10 degrees, a 20 percent rating if limited to 15 degrees, a 30 percent rating if limited to 20 degrees, a 40 percent rating if limited to 30 degrees, and a 50 percent rating if limited to 45 degrees. Id. A knee disability can be assigned separate ratings for both limitation of leg flexion under Diagnostic Code 5260 and limitation of leg extension under Diagnostic Code 5261. See VAOPGCPREC 9-2004 (Sept. 17, 2004). Similarly, separate ratings may also be assigned for lateral instability and/or recurrent subluxation of the knee under Diagnostic Code 5257. Under 38 C.F.R. § 4.71a, Diagnostic Code 5257 covers "other impairment of the knee," and an assignment of a 10 percent rating is warranted when there is slight recurrent subluxation or lateral instability. A 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability. A 30 percent evaluation is for severe knee impairment with recurrent subluxation or lateral instability. When assigning a disability rating, it is necessary to consider functional loss due to flare-ups, fatigability, incoordination, and pain on movements. See DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). The rating for an orthopedic disorder should reflect functional limitation due to pain which is supported by adequate pathology and evidenced by the visible behavior of the Veteran undertaking the motion. Weakness is also as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity, or the like. See 38 C.F.R. § 4.40. The factors of disability reside in reductions of their normal excursion of movements in different planes. Instability of station, disturbance of locomotion, and interference with sitting, standing, and weight bearing are related considerations. See 38 C.F.R. § 4.45. It is the intention of the rating schedule to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimal compensable rating for the joint. 38 C.F.R. § 4.59. It is the Board's responsibility to determine whether a preponderance of the evidence supports the claim or whether the evidence is in relative equipoise, with the veteran prevailing in either event, or whether there is a preponderance of evidence against the claim, in which case the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). On the Veteran's April 2008 pre-retirement physical, the Veteran reported bilateral knee pain with periodic giving way. At an October 2008 VA examination, the Veteran reported chronic knee pain bilaterally, described as sharp but intermittent. October 2008 x-rays of the knees revealed minimal medial compartment degenerative change bilaterally, and a small left patellar enthesophyte. The Veteran reported that both knees give way. He reported pain, instability, stiffness and weakness in both knees. The Veteran reported severe flare-ups of knee pain, decreased motion, and inflammation every 3 to 4 months lasting 1 to 2 weeks. Examination of the knees revealed flexion to 110 degrees, but pain began at 90 degrees. Extension was to -5..The Veteran reported, however, that during a flare-up he is unable to fully straighten his knees. A private orthopedic examination report from April 2010 indicates that more current x-rays reveal moderate to severe bilateral patellar osteoarthritis. Pain is usually triggered when he runs, but he continues to run twice per week for about two and half miles. On examination, the Veteran could walk on heels and toes without difficulty, although some anterior knee pain was noted during crouching. Patellar grind test was positive and patellofemoral crepitus was 3+ to 4+. Flexion was full bilaterally without pain and there was no limitation of extension. Similarly, no laxity was identified. An August 2017 MRI of the left knee revealed edema, but no evidence of ligament or meniscal damage. The Veteran's range of motion of both knees is noncompensable under Diagnostic Codes 5260 and 5261; however, because he has x-ray evidence of arthritis, 10 percent ratings were assigned for each knee. To warrant the next higher, 20 percent rating, knee flexion would have to be limited to 30 degrees or less, and/or knee extension would have to be limited to 15 degrees or higher. This has never been shown, even with consideration of additional loss of motion due to pain and swelling during flare-ups. Accordingly, disability ratings in excess of 10 percent for the right and left knees on the basis of limitation of motion are not warranted. Although stability testing did not confirm instability of either knee, it is clear that the Veteran was not in a period of flare-up of either knee, and there is no reason to doubt the Veteran's credible statements that his knee gives way periodically. In this case, the Veteran is competent to testify on factual matters of which he has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). The Veteran is competent to provide evidence of observable symptoms, including pain and giving way. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). See also Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). The Veteran is competent to describe his symptoms and their effects on employment or daily activities. His statements are probative for resolving this appeal. Accordingly, the Board finds that the Veteran's right and left knee symptoms include occasional instability. In this regard, the evidence does not show, and the Veteran has not argued, that any such instability is more than slight in degree, and this is consistent with the examiner's stability testing when the Veteran was not in a period of flare-up. Thus, in resolving all doubt in favor of the Veteran, the Board finds that separate 10 percent ratings are warranted for slight instability of the right knee and slight instability of the left knee. The Board has also considered whether a TDIU (total disability rating for compensation based on individual unemployability) claim has been raised by the record and finds that it has not. The Veteran does not assert, and the evidence does not show, that he is unable to work solely on account of his service-connected right and left knee arthritis. Accordingly, the Board finds that a claim for TDIU is not raised by the record Rice v. Shinseki, 22 Vet. App. 447 (2009). ORDER Service connection for right wrist arthritis is denied. Service connection for left wrist arthritis is denied. Service connection for right wrist CTS is granted. Service connection for left wrist CTS is granted. Service connection for a respiratory/breathing disorder is denied. Service connection for a bilateral hearing loss disability is denied. A disability rating in excess of 10 percent for the service-connected right knee osteoarthritis, on the basis of limited motion, is denied. A disability rating in excess of 10 percent for the service-connected left knee osteoarthritis, on the basis of limited motion, is denied. A separate 10 percent disability rating for slight instability of the right knee is granted, subject to the laws and regulations governing the payment of monetary benefits. A separate 10 percent disability rating for slight instability of the left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. REMAND As noted in the Introduction above, service connection for IBS with an initial 10 percent rating was granted in a December 2011 rating decision. In a March 2012 NOD, the Veteran disagreed with the initial 10 percent rating assigned for the IBS. The RO has not yet issued an SOC addressing this issue, and it does not appear that any additional development has been undertaken with respect to this issue since the Veteran's NOD was received in March 2012. The RO is now required to send the Veteran an SOC as to the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected IBS in accordance with 38 U.S.C. § 7105 (2012) and 38 C.F.R. §§ 19.29, 19.30 (2017). Where a Notice of Disagreement has been submitted, the Veteran is entitled to a Statement of the Case. The failure to issue a Statement of the Case is a procedural defect requiring a remand. Manlincon v. West 12 Vet. App. 238 (1999); Godfrey v. Brown, 7 Vet. App. 398 (1995). Accordingly, the case is REMANDED to the RO for the following action: Provide the Veteran with a Statement of the Case as to the issue of entitlement to an initial disability rating in excess of 10 percent for the service-connected IBS in accordance with 38 U.S.C. § 7105 (2012) and 38 C.F.R. §§ 19.29, 19.30 (2017). If the Veteran perfects his appeal by submitting a timely and adequate substantive appeal, then the RO should return the claim to the Board for the purpose of appellate disposition. 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). ______________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs