Citation Nr: 1817954 Decision Date: 03/23/18 Archive Date: 04/03/18 DOCKET NO. 13-31 611 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to an initial rating in excess of 10 percent for low back strain. 2. Entitlement to an initial rating in excess of 10 percent for left ankle strain. 3. Entitlement to a rating in excess of 20 percent for residuals of an avulsion fracture of the right ankle. 4. Entitlement to a rating in excess of 10 percent for healed fracture of the 5th metatarsal of the left foot with residual hardware and a scar, to include restoration of a 20 percent rating from April 13, 2012. 5. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee. 6. Entitlement to a compensable rating for left knee scars, to include restoration of a 10 percent rating from April 13, 2012. 7. Entitlement to a rating in excess of 30 percent for pseudofolliculitis barbae and tinea versicolor, to include restoration of a 30 percent rating for tinea versicolor effective July 1, 2014. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD A. Shawkey, Counsel INTRODUCTION The Veteran served on active duty from August 1996 to August 2000. This matter comes to the Board of Veterans' Appeals (Board) on appeal from October 2009, August 2010, November 2012, and April 2014 rating decisions of the Department of Veterans Affairs (VA) Regional Offices (ROs). In January 2016, the Veteran testified at a Board hearing held at the RO. The Veterans Law Judge (VLJ) who conducted that hearing is no longer at the Board. In October 2017, the Veteran was given the opportunity to request a new hearing before another VLJ pursuant to 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. However, the Veteran informed the Board in writing in November 2017 that he did not wish to have another hearing. This matter was previously before the Board in July 2016 at which time the Board reopened and granted the claim of entitlement to service connection for a right knee disability, and remanded the issues as noted on the title page of this decision to the Agency of Original Jurisdiction (AOJ) for additional development. There has been substantial compliance with the AOJ's remand directives. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the period prior to September 27, 2016, the Veteran's low back strain was manifested by pain on motion of the lumbar spine on examination, but did not cause limitation of flexion to 60 degrees or less, or combined range of motion of the thoracolumbar spine to 120 degrees or less, or muscle spasm, guarding, or localized tenderness severe enough to result in abnormal gait or abnormal spinal contour, did not demonstrate neurologic impairment, and/or did not cause incapacitating episodes as defined by VA. 2. From September 27, 2016, the Veteran's low back strain has been productive of limitation of flexion to 60 degrees. 3. Throughout the duration of this appeal, the Veteran's left ankle disability has been manifested by functional impairment due to pain and instability analogous to marked limitation of motion. 4. Throughout the duration of this appeal, the Veteran's right and left ankle disabilities have not been productive of ankylosis. 5. From April 13, 2012, the Veteran's residuals of a fracture of the 5th metatarsal of the left foot have been productive of a moderately severe foot injury with no actual improvement 6. The November 2012 rating decision that decreased the rating for residuals of a fracture of the 5th metatarsal of the left foot from 20 to 10 percent based on actual improvement was improper. 7. Throughout the duration of this appeal, residuals of a fracture of the 5th metatarsal of the left foot have not been productive of more than a moderately severe foot injury. 8. Throughout the duration of this appeal, the Veteran's service-connected left knee disability has been manifested by a meniscal tear, degenerative joint disease, locking, constant pain, and effusion; range of motion was no worse than 0 to 90 degrees, there was no recurrent subluxation or lateral instability, and no ankylosis. 9. The November 2012 rating decision, which reduced a disability rating for left knee scars from 10 percent to noncompensable effective April 13, 2012, due to actual improvement was proper. 10. From April 13, 2012, the Veteran's three left knee scars have not been found to be tender, painful or unstable on examination, they are superficial, involve an area less than 6 square inches (77 square centimeters), and do not result in functional impairment of an affected part. 11. The April 2014 rating decision, which reduced the Veteran's rating for tinea versicolor to a single 30 percent rating by combining skin disabilities, was proper. 12. Throughout the duration of this appeal, the Veteran's tinea versicolor and pseudofolliculitis affect more than 40 percent of exposed areas during flare ups. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 10 percent rating for low back strain have not been met for the period prior to September 27, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 2. The criteria for an increased initial rating, to 20 percent, but no higher, for low back strain have been met for the period from September 27, 2016. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2017). 3. Resolving reasonable doubt in the Veteran's favor, the criteria for an increased initial rating, to 20 percent, but no higher, for the Veteran's left ankle disability have been met throughout the duration of this appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 4. The criteria for a rating in excess of 20 percent for the Veteran's right ankle disability have not been met at any point during the duration of this appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271 (2017). 5. The criteria for restoration of a 20 percent rating for residuals of a left foot 5th metatarsal fracture with a scar, effective April 13, 2012, have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.344, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2017). 6. The criteria for a disability rating in excess for 20 percent for residuals of a left foot 5th metatarsal fracture with a scar have not been met. 38 U.S.C.A. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 3.321, 4.71a, Diagnostic Code 5284 (2017). 7. Throughout the duration of this appeal, the criteria for an increased rating, to 20 percent, but no higher, for the Veteran's left knee disability have been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.40. 4.45, 4.71a, Diagnostic Codes 5257, 5258, 5260, 5261 (2017). 8. The criteria for restoration of a 10 percent rating for the Veteran's left knee scars effective April 13, 2012, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.344, 4.3, 4.7, 4.118, Diagnostic Codes 7801-7805 (2017). 9. The criteria for a rating greater than 10 percent for left knee scars prior to April 13, 2012, are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321(b), 4.7, 4.118, Diagnostic Codes 7801-7805 (2017). 10. The criteria for restoration of a 30 percent rating for service-connected tinea versicolor, effective July 1, 2014, have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.344, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes7806, 7820 (2017). 11. Resolving reasonable doubt in the Veteran's favor, the criteria for a disability rating of 60 percent, but no higher, for the Veteran's service-connected pseudofolliculitis barbae and tinea versicolor, have been met for the entire rating period on appeal. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.118, Diagnostic Code 7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. General Rating Provisions Disability evaluations are determined by application of the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment. 38 C.F.R. § 4.1. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where 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). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination. See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. A rating reduction is the result of a course of action taken by VA, and not a claim by the Veteran. The regulation governing rating reductions, 38 C.F.R. § 3.105 (e), contains its own notice provisions and procedures. When the propriety of a rating reduction is at issue, the focus is on the actions of the RO in effectuating the reduction, both in terms of compliance with the special due process considerations applicable to reductions, and in terms of whether the evidence at the time of the decision reducing the evaluation supported the reduction. In most cases, violations of the set of due process considerations applicable to rating reductions, or failure of the evidence to meet the standards for reducing an evaluation, render the underlying reduction void ab initio, rather than merely voidable. The burden is on VA to justify a reduction in a rating. See Brown v. Brown, 5 Vet. App. 413 (1993) (finding that the Board is required to establish, by a preponderance of the evidence and in compliance with 38 C.F.R. § 3.344, that a rating reduction is warranted). II. Analysis A. Back Disability Pertinent Criteria Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, Diagnostic Code (Code) 5237. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 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 rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and 100 percent for unfavorable ankylosis of the entire spine. Note 1 to the rating formula specifies that any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, should be separately evaluated under an appropriate Code. Note 2 states that, for VA compensation purposes, normal forward flexion of the cervical spine is 0 to 45 degrees, extension is 0 to 45 degrees, left and right lateral flexion are 0 to 45 degrees, and left and right lateral rotation are 0 to 80 degrees. For the thoracolumbar spine, normal flexion 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 combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion is 240 degrees for the thoracolumbar spine. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Intervertebral disc syndrome (IVDS) (preoperatively or postoperatively) is to be evaluated 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 evaluation when all disabilities are combined under § 4.25. A 10 percent disability rating is assigned for incapacitating episodes having a total duration of at least one week but less than two weeks during the past twelve months, with higher evaluations for incapacitating episodes of increased duration. Note 1 states that 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 indicates that if intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, the rater is to evaluate each segment 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. Facts Private chiropractic treatment records on file in 2009 show treatment for complaints of low back discomfort. These records show that the Veteran had normal active lumbar range of motion. The Veteran reported at a VA examination in June 2010 that he experienced nonradiating low back pain. Findings revealed active flexion to 80 degrees, extension to 30 degrees, and right and left lateral flexion and rotation to 30 degrees on each side, all without pain. The combined range of motion of the thoracolumbar spine was 230 degrees. There was no additional loss of motion on repetitive use testing. In regard to abnormalities of the spine muscle such as guarding, spasm, tenderness, weakness, or atrophy, no such abnormalities were found. There was also no ankylosis of the thoracolumbar spine, and the Veteran had a normal gait. In regard to flare ups, the Veteran reported have flare-ups once a week that required him to lie down for approximately 30 minutes. The examiner did not comment on incapacitating episodes as far as the Veteran's lumbar condition. The Veteran testified in January 2016 that he can never get comfortable because of his back pain and that it affects his sleep. He said that he has to lie down if he walks too much. He added that chiropractic care helps, but it is expensive. At a VA examination on September 27, 2016, the Veteran reported mild back pain without radiation and mild difficulty with lifting. Range of motion findings revealed lumbar flexion from 0 to 60 degrees, extension to 30 degrees, and right and left lateral flexion and rotation to 30 degrees on each side. His combined range of motion of the lumbar spine was 210 degrees. He had functional loss due to pain which the examiner described as lifting difficulty. There was no additional loss of motion or loss of function after repetition, and there was no guarding or muscle spasm. The Veteran did not have ankylosis of the spine. Discussion In terms of the VA examinations noted above, it should be noted that the Court of Appeals for Veterans Claims addressed in Correia v. McDonald, 28 Vet. App. 158 (2016), the proper interpretation of the final sentence of 38 C.F.R. § 4.59 stating, "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and non weight-bearing and, if possible, with the range of the opposite undamaged joint". In this regard, the Court concluded that VA examinations should include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Here, pertinent VA examinations of the lumbar spine did not include passive range of motion, but did include consideration of pain on weight bearing and range of motion after repetitive motions. In short, the Board finds that the testing that was conducted during the VA examinations affords an accurate measurement of the most limited range of motion of the Veteran's lumbar spine as passive range of motion tends to yield a less restrictive range of motion. The findings outlined above do not meet the criteria for a higher than 10 percent rating for the period prior to September 27, 2016. This is based on the normal range of motion findings as noted in private chiropractic records in 2009, and on findings at the June 2010 VA examination showing limitation of flexion to 80 degrees and a combined range of motion of the thoracolumbar spine of 230 degrees. The evidence simply does not meet the criteria under Code 5237 for a 20 percent rating based on a strict adherence to the rating criteria (requiring limitation of flexion to 30 degrees or less but not greater than 60 degrees, or combined range of motion of the thoracolumbar spine to 120 degrees or less, or muscle spasm, guarding, or localized tenderness severe enough to result in abnormal gait or abnormal spinal contour), nor does it show that his back disability is the functional equivalent of such criteria due to factors such as pain. 38 C.F.R. § 4.71a, Code 5237; see also DeLuca v. Brown, 8 Vet. App. at 204-207. Thus, the preponderance of the evidence is against a higher than 10 percent rating for the period prior to September 27, 2016, the benefit-of-the-doubt doctrine does not apply and the claim to this extent is denied. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Regarding the period from September 27, 2016, the Board finds that the Veteran meets the criteria for a higher rating to 20 percent. This is based on the finding at the September 27, 2016, VA examination of limitation of flexion to 60 degrees. This finding satisfies the criterion for a 20 percent rating requiring forward flexion greater than 30 degrees, but not greater than 60 degrees. 38 C.F.R. § 4.71, Code 5237. A higher than 20 percent rating is not warranted under this code absent evidence of forward flexion of the thoracolumbar spine 30 degrees or less or the functional equivalent thereof; or, favorable ankylosis of the entire thoracolumbar spine. The September 2016 VA examiner specifically noted that the Veteran did not have ankylosis of the spine. The Board has also considered other appropriate diagnostic codes, particularly Diagnostic Code 5243 for IVDS. However, the Veteran has not asserted nor do findings show that he has radicular symptoms nor have any other neurologic abnormalities been noted. Rather, the September 2016 VA examiner reported that the Veteran did not have IVDS of the thoracolumbar spine. This is consistent with the Veteran's report in June 2010 of nonradiating low back pain. Accordingly, the Board finds that a higher rating under the Formula for Rating IVDS based on Incapacitating Episodes is not warranted. For the foregoing reasons, a higher than 10 percent rating is not warranted for low back strain at any point prior to September 27, 2016, and a higher rating of 20 percent, but no higher, is warranted from September 27, 2016. B. Right and Left Ankle Disabilities Pertinent Criteria Under Diagnostic Code 5271 for limitation of motion of the ankle, a 10 percent rating is assigned for moderate limitation of motion, and a 20 percent rating is assigned for marked limitation of motion. The 20 percent rating is the maximum rating available under Code 5271. Normal range of ankle motion is from 20 degrees of upward dorsiflexion to 45 degrees of downward plantar flexion. 38 C.F.R. § 4.71, Plate II. The Board observes that the words "moderate" "moderately severe," and "marked," as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Use of such terminology by VA examiners and others, although evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Under Diagnostic Code 5270, ankylosis of the ankle in plantar flexion less than 30 degrees warrants a 20 percent rating. If ankylosed in plantar flexion, between 30 degrees and 40 degrees, or in dorsiflexion, between 0 degrees and 10 degrees, a 30 percent rating is warranted. If ankylosed in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity, a 40 percent rating is warranted. 38 C.F.R. § 4.71a. Ankylosis is defined as stiffening or fixation of a joint as the result of a disease process, with fibrous or bony union across the joint. STEDMAN'S MEDICAL DICTIONARY 90 (27th Ed. 2000). Facts Records from Advanced Orthopaedic Centers in 2009 show that the Veteran had become increasingly concerned with his right ankle. He underwent a right ankle magnetic resonance imaging (MRI) in February 2009 which showed evidence of osteochondral injury on the talar dome, some chronic tearing of the anterior talofibular ligament, and some degenerative changes at the talonavular joint. All of his symptoms on the right side were noted to be at the anteriolateral ankle joint. He had excellent range of motion and there was no significant synovitis noted. The examiner opined that the Veteran probably had a soft tissue impingement lesion in his right ankle which was not severe enough to require surgery. Conservative measures were discussed. The Veteran reported at a VA examination in June 2009 that his right ankle was painful on walking and during cold weather and that it radiated across his ankle. He added that he was unable to stand for more than a few minutes or walk more than a few yards due to his right ankle. He reported using a right ankle brace intermittently. On examination he had an antalgic gait. Right ankle findings were positive for crepitus, tenderness and edema, and negative for instability and tendon abnormality. Range of motion on dorsiflexion was 0 to 10 degrees and plantar flexion was 0 to 35 degrees. Pain was noted on range of motion, but there was no additional limitation after three repetitions. There was no ankle joint ankylosis. Regarding the left ankle, findings were positive for crepitus, and negative for instability or tendon abnormality. Left ankle range of motion on dorsiflexion was 0 to 18 degrees and plantar flexion was 0 to 38 degrees. Pain was noted on range of motion, but there was no additional limitation after three repetitions. There was no ankle joint ankylosis. In March 2010, the Veteran was examined at a private orthopedic clinic for left ankle problems. Findings revealed tenderness over both medial and lateral malleolar areas. There was no effusion. Dorsiflexion lacked 5 degrees and other ranges of motion appeared normal. The Veteran reported at a June 2010 VA examination that he had a history of left ankle sprains and that the last sprain occurred approximately one month earlier. He said that he treated the sprains conservatively with ice and pain medication. He estimated being able to walk about a block. He said he wore a brace on his right ankle daily. He was observed walking with a limp. Examination findings revealed no ankle instability or tendon abnormality. Range of motion in both ankles revealed plantar dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. There was no pain on motion and no additional limitation after repetition. There was also no ankle ankylosis. An X-ray taken of the left ankle was normal. The Veteran testified in January 2016 that his right ankle is painful and unstable and is affected by cold weather. He said that it prohibits him from performing certain activities like riding a bike and playing sports. He also said that his left ankle is similar with pain and instability issues and that the only difference between the ankles is that he fractured his right ankle. He said his ankles affect his work in that he is unable to get into a squatting position. He also said he has seen many doctors for his ankles and takes over-the-counter pain medication. Range of motion findings at a VA examination in December 2016 were normal with respect to the right and left ankles with dorsiflexion from 0 to 20 degrees and left ankle plantar flexion from 0 to 45 degrees. There was no pain, tenderness or crepitus found on examination. The Veteran's ankle disabilities were noted to cause difficulty with prolonged standing and walking/disturbance of locomotion. There was no additional loss of function or range of motion in either ankle after repetitive use, to include due to pain, weakness, fatigability or incoordination. Muscle strength was 5/5 and there was no ankle ankylosis. There was also no ankle instability or dislocation. Discussion i. Rating Greater Than 10 Percent for the Left Ankle In light of the facts above, the Board finds that for the duration of this appeal period the Veteran's overall disability picture for the left ankle more closely approximates the criteria for a 20 percent rating for marked limitation of motion under Code 5270. In this regard, findings and complaints with respect to the Veteran's left ankle are essentially identical to findings and complaints for his right ankle for which he is presently rated as being 20 percent disabled. This is evident when considering the Veteran's reports at various examinations as well at as his January 2016 Board hearing that his left ankle symptoms are similar to his right ankle symptoms and include pain on motion and instability. In fact, he testified that the only difference between the two ankle disabilities is that he fractured his right ankle. Although the examiners in June 2010 and December 2016 found no objective evidence of pain on motion when performing range of motion testing which was essentially normal, the examiners nevertheless noted that the Veteran was functionally limited due to his ankles because of decreased mobility and pain. The Veteran also testified that he is unable to squat and that his ankles get stiff when walking and on prolonged sitting. He added that he takes medication for the pain. He is competent to testify to such lay observable symptomatology, and there is no evidence that these statements are not credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). After considering functional loss of the Veteran's left ankle due to pain which functionally impedes his ability to walk and sit for prolonged periods of time, his reports of left ankle instability, and by resolving all reasonable doubt in his favor, the Board finds that a 20 percent rating is warranted for the left ankle. 38 C.F.R. § 4.3. That is, the Board finds that the Veteran's left ankle disability more closely approximates the criteria for marked limitation of motion. 38 C.F.R. § 4.7. Accordingly a 20 percent rating under Diagnostic Code 5271 for the Veteran's left ankle is warranted for the entire appeal period from May 15, 2009. ii. Rating Greater Than 20 Percent for the Right and Left Ankles As noted, under Code 5271 for limitation of ankle motion, 20 percent is the maximum allowable rating. As such, a higher rating under this code is not warranted even after considering symptoms of functional loss under 38 C.F.R. § 4.40 and § 4.45. Johnston v. Brown, 10 Vet. App. 80, 84 (1997). On a similar note, the application of Correia is essentially negated here by the fact that the Veteran has been assigned the maximum schedular rating for limitation of motion of the right and left ankles. Id. The only code under VA's rating schedule that warrants a higher than 20 percent rating for ankle disability is Code 5270 for ankylosis. However, the evidence in this case does not suggest that the Veteran has ankylosis in the right ankle. In fact, findings at the June 2009, June 2010 and December 2016 VA examinations specifically note that the Veteran does not have ankylosis of the ankle joints. Thus, a higher rating under Code 5270 is not warranted. Also, as the ankle is the affected area the disability would not be appropriately rated as a foot injury under Code 5284. 38 C.F.R. § 4.71a. In light of the above, the Board finds that the preponderance of the evidence is against the claims for a rating in excess of 20 percent for the Veteran's right and left ankle disabilities for the entire period on appeal. Thus, as the preponderance of the evidence is against higher ratings, the benefit-of-the-doubt doctrine does not apply and the claims to this extent are denied. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). C. Left Foot Disability Pertinent Criteria Foot disabilities are governed by the provisions of 38 C.F.R. § 4.71a, Codes 5276 through 5284. These provisions include a 10 percent rating under Code 5279 for metarsalgia, anterior (Morton's Disease), unilateral, or bilateral. Under Code 5284 for other foot injuries, a 10 percent evaluation is warranted for moderate residuals of foot injuries, a 20 percent evaluation for moderately severe residuals, and a 30 percent rating requires severe residuals of foot injuries. A 40 percent rating contemplates actual loss of use of the foot. The terms "mild," "moderate," and "severe" are not defined in the Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The use of terminology such as "moderate" or "severe" by VA examiners and others, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Facts By way of history, the Veteran had two injuries to his left foot in service. The first injury involved a 5th metatarsal fracture that required open reduction internal fixation (ORIF) with screws and metallic wire. The second injury resulted in the removal of one of the screws which had become fractured. Private orthopedic treatment records from October 2008 to December 2008 show that the Veteran had ongoing trouble with his left foot due to residuals his left 5th metatarsal fracture. These records note that the left foot was still tender at the 5th metatarsal despite two previous surgeries and two remaining screws and wire fixation. At a June 2009 VA examination, the Veteran reported that his condition has become progressively worse. He said that he treated the condition with medication and he reported pain in the left fifth toe and across the top of the foot. On examination there were no signs of infection, bone disease, genu recurvatum or malunion of the os calcis or astragalus. His gait was antalgic and there was evidence of abnormal weight bearing. He was limited on standing and walking. Deformity was noted with an abnormal fifth metatarsal and edema at the proximal fifth metatarsal. There was no evidence of malunion, nonunion, false joint, loss of a bone or part of a bone or angulation. This condition was noted to not affect the motion of a joint. The x-ray did not show evidence of acute fracture, but did show evidence of the previous ORIF surgery in 1996. The examiner diagnosed the Veteran as having a healed fracture of the 5th metatarsal left foot with residual hardware in place. The Veteran reported at an April 2012 VA examination that his left foot continued to hurt on a regular basis since service, and that it was worse during cold weather. He denied wearing a brace and said that he takes over-the-counter pain medication. Examination of the left foot revealed a lateral, well-healed surgical scar over the fifth metatarsal. There was no localized tenderness or swelling. He was not found to have any limitation of the left foot on dorsiflexion. The examiner also reported that the metallis suture and screws in place over the 5th metatarsal were in good position. He said that the Veteran's left foot 5th metatarsal fracture was completely healed, as was the surgical scar. He went on to note that there was no localized swelling or tenderness and no degenerative joint disease on x-ray at all. He reported that the Veteran had metatarsalgia on the left and that the Veteran's chronic left foot pain would limit his ability to perform prolonged walking and standing. In November 2012, the RO reduced the Veteran's rating for his left foot disability from 20 to 10 percent disabling under Code 5279, effective the date of the April 2012 VA examination. Findings at a VA examination in September 2016 VA reveal that the Veteran's left foot disability caused pain on weight bearing and disturbance of locomotion. The examiner did not report evidence of limitation on dorsiflexion. He did report that factors such as pain, weakness, incoordination and fatigability did not significantly limit the Veteran's functional ability during flare-ups or on repeated use. A scar was noted on the lateral aspect of the left mid foot measuring 7 cm x .3 cm in length which was not painful or unstable. Left foot x-rays taken in 2009 were interpreted as showing ORIF of the proximal fifth metatarsal with placement of two screws and cerclage wires. Alignment was within normal limits. Significant degenerative changes were not evident and there was no evidence of acute fracture. The Veteran's ability to perform occupational tasks was noted to be impacted by his difficulty with prolonged standing and walking. Discussion i. Restoration of 20 Percent Rating Effective April 13, 2012 In an October 2009 rating decision, the RO assigned a compensable, 20 percent, disability rating for the Veteran's left foot disability based on symptoms that were found to more closely approximate a moderately severe foot injury under Code 5284. This rating was made effective the date of the Veteran's May 15, 2009, claim. The Veteran appealed this rating and, during the course of the appeal in November 2012, the RO implemented a reduction to 10 percent for the left foot disability, effective the date of an April 13, 2012, VA examination. The RO at this time changed the Veteran's left foot disability rating from Code 5284 for other foot injury to Code 5279 for metatarsalgia. Here, as the reduction in evaluation of the service-connected left foot disability did not result in a reduction of compensation payments being made to the Veteran, a rating decision proposing the reduction was not necessary and the notice requirements of 38 C.F.R. § 3.105 (e) are not applicable here. Moreover, as this rating has been in effect for less than five years, re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344 (c) (2017). Here, the evidence does not show improvement in the Veteran's left foot disability. In this regard, although the April 2012 VA examiner reported that the Veteran's left foot fracture was well healed, he also noted that there was objective evidence of residual left foot pain resulting in pain on weightbearing and disturbance of locomotion. He went on to report that this impacted the Veteran in an occupational setting with respect to difficulty with prolonged walking and standing. These functional limitations, as well as left foot pain, are similarly noted on a June 2009 VA examination report and on a more recent VA examination report in September 2016. Thus, despite the fact that the Veteran's left fracture is well healed, he is still shown to have residual pain and functional limitations which have remained constant throughout the appeal period. In light of the above, the overall weight of the evidence does not show improvement in the Veteran's service-connected left foot disability. Consequently, the criteria for a rating reduction under 38 C.F.R. § 3.344(c) have not been met and the Veteran is thus entitled to restoration of the 20 percent rating for his service-connected left foot disability, effective April 13, 2012. ii. Rating Greater Than 20 Percent for Left Foot Disability While there is no disputing that the Veteran experiences pain in his left foot and disturbance of locomotion by way of difficulty with prolonged standing and walking, the Board does not find that the residuals of his service-connected left foot disability approximate more than a moderate disability. This is so after considering the lack of findings of actual limitation of motion of the left foot on examination and the no more than moderate impact that the Veteran's left foot disability has on his occupation. See 38 C.F.R. § 4.1 (percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such disease and injuries and their residual conditions in civil occupations.) In this regard, the Veteran testified in January 2016 that he works as a professional services engineer in telecommunications and works on customers' equipment. He said that his left foot disability impacts his employment due to his inability to squat and to get into certain positions. The examiners also noted that he is limited on prolonged standing and walking. These limitations moderately affect the Veteran's occupation. Additionally, there are no other diagnostic codes that warrant a higher rating. In this regard, the Veteran has not been found to have pes planus, pes cavus, or malunion or nonunion of the tarsal or metatarsal bones, and the medical manifestations of the Veteran's foot disorder are not analogous to those disabilities. Accordingly, increased ratings are not warranted under 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5278, or 5283 (2017). The Board has also considered whether it may be appropriate to rate the Veteran's scar under Codes 7801-7805. 38 C.F.R. § 4.118, Diagnostic Codes 7800-7805. Diagnostic Code 7801 provides a 10 percent rating for deep, nonlinear scars of other than head, face, or neck, that are at least 6 square inches but no more than 12 square inches, and Diagnostic Code 7802 provides a 10 percent rating for scars, other than head, face, or neck, that were superficial and nonlinear, with an area or areas of 144 square inches (929 sq. cm.) or greater. Diagnostic Code 7804 provides a 10 percent rating for one or two scars that are unstable or painful. The Veteran's scar is less than 6 square inches, so it is not compensable under either Code 7801 or 7802. Also, the scar was noted by the April 2012 VA examiner to be well healed, and it was noted by the September 2016 VA examiner to not be painful or unstable, measuring 7 cm x .3 cm. Accordingly, a compensable rating for a left foot scar under Code 7804 is not warranted. Finally, there are no unaccounted disabling symptoms to warrant the assignment of a separate rating under Diagnostic Code 7805. D. Degenerative Joint Disease, Left Knee Pertinent Criteria Limitation of motion of the knee is rated under either Diagnostic Code 5260 (limitation of flexion) or Diagnostic Code 5261 (limitation of extension). Under Diagnostic Code 5260, flexion limited to 45 degrees is 10 percent disabling, flexion limited to 30 degrees is 20 percent disabling, and flexion limited to 15 degrees is 30 percent disabling. Under Diagnostic Code 5261, extension limited to 10 degrees is 10 percent disabling, extension limited to 15 degrees is 20 percent disabling, and extension limited to 20 degrees is 30 percent disabling. Normal range of motion of the knee motion is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II. Instability of the knee is rated under Diagnostic Code 5257. Under Diagnostic Code 5257, a 10 percent rating is warranted for slight knee impairment, that is, recurrent subluxation or lateral instability. A 20 percent rating is assigned for a moderate degree of impairment, and a maximum rating of 30 percent is assigned for severe impairment. Knee disabilities may also be rated under Diagnostic Codes 5256, 5258, 5259, 5262, and 5263. Under Diagnostic Code 5256, ratings of up to 60 percent are available for ankylosis of the knee. Under Diagnostic Code 5258, a 20 percent rating may be assigned for dislocation of the semilunar cartilage, with frequent episodes of "locking", pain, and effusion into the joint. Under Diagnostic Code 5259, a 10 percent rating may be assigned for symptomatic removal of semilunar cartilage. Under Diagnostic Code 5262, ratings of 10, 20, and 30 percent, respectively, can be assigned for malunion of the tibia and fibula with slight, moderate, or marked knee or ankle disability. If there is nonunion of the tibia and fibula, with loose motion requiring a brace, a 40 percent rating is assigned. Finally, Diagnostic Code 5263 provides a single 10 percent rating for genu recurvatum, acquired, traumatic, with weakness and insecurity in weight-bearing objectively demonstrated. VA General Counsel has held that separate ratings may be assigned in cases where a service-connected knee disability includes both limitation of motion due to arthritis and instability, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 23-97, 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98, 63 Fed. Reg. 56704 (1998). The basis for this opinion was that the applicable rating criteria, "suggest that those Codes apply either to different disabilities or to different manifestations of the same disability..." VAOPGCPREC 23-97. The General Counsel subsequently clarified in VAOPGCPREC 9-98 (August 14, 1998) that for a knee disability rated under DC 5257 to warrant a separate rating for arthritis based on X- ray findings and limitation of motion, limitation of motion under Code 5260 or Code 5261 need not be compensable but must at least meet the criteria for a zero percent rating. VA's General Counsel further explained that, if a veteran has a disability rating under DC 5257 for instability of the knee, a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59. VA General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under Diagnostic Code 5260, and a compensable limitation of extension under Diagnostic Code 5261 provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The basis for the opinion was a finding that a limitation in planes of movement were each compensable. Id. Facts Private outpatient records show that the Veteran was seen at an orthopedic facility as a new patient in October 2008 with left knee complaints. Findings in November 2008 and December 2008 include tenderness anteriorly with crepitus and to a lesser degree along the medial joint line. There was full extension and flexion, and no valgus/varus instability at 0 degrees and 30 degrees. Lachman and posterior drawer testing were negative. There were no McMurray findings. At a VA examination in June 2009, the Veteran complained of left knee pain with prolonged sitting, walking and running. Findings were negative for instability, but were positive for edema and tenderness. Range of motion of the left knee was 0 to 90 degrees with normal extension, and there was no objective pain on motion. A private orthopedic record in March 2010 reflects the Veteran's complaints of left knee pain. On examination an obvious clunk was noted laterally that was visible. Palpation revealed a fairly movable loose body that may have been adhered to the joint line. There was moderate to severe parapatellar tenderness. Also noted was exquisite pain over the medial joint line area. Ligamentous testing revealed no laxity. Flexion lacked 15 degrees and extension was full. Magnetic resonance imaging (MRI) of the left knee taken at that time revealed a tear of the medial meniscus. The views also showed a possible loose body adjacent to the patella laterally. The Veteran was assessed as having bilateral-patellofemoral pain. Knee exercises were recommended as well as arthroscopic surgery on the left knee. The Veteran reported on a VA Form 21-2142 dated in April 2010 that he was leery of undergoing another left knee surgical procedure. At a VA examination in April 2012, the Veteran reported that his left knee swells up and that the pain gets worse with increased physical activity. Flexion was to 120 degrees with pain, and extension was to 0 degrees with no pain. There was no additional limitation of motion on repetitive-use testing. Anterior, posterior and medial lateral instability tests were normal. There was no recurrent subluxation or dislocation. The Veteran was noted to have a meniscus (semi lunar) condition with frequent episodes of locking, pain and effusion. He was diagnosed as having degenerative joint disease of the left knee. Private orthopedic findings in February 2013 revealed left knee flexion to 135 degrees on active and passive range of motion. Extension was to 0 degrees on both active and passive range of motion. The Veteran complained of worsening left knee pain at that time. He was seen again in September 2016 for a new left knee thruster brace. Tenderness was noted as well as trace effusion and muscle atrophy 10 to 20 percent. Active range of motion revealed flexion to 130 degrees and extension to 20 degrees. The Veteran complained of increasing left knee pain at a VA examination in September 2016. Range of motion was abnormal with flexion from 0 to 100 degrees and extension from 100 to 0 degrees. These findings were noted to affect functional loss by making stair climbing difficult. Pain was noted on examination and there was functional loss due to pain. Also noted was mild tenderness in the medial joint line. There was no additional functional loss after repetitive testing. Pain, weakness, fatigability or incoordination did not significantly limit functional ability with repeated use over a period of time. Muscle strength was reduced to 4/5. There was no left knee ankylosis or instability. The examiner reported that this disability impacted the Veteran's employment status due to difficulty sitting bending, walking and climbing. Discussion The Veteran's left knee disability is currently rated as 10 percent disabling, under Code 5259 for cartilage, semilunar, removal of, symptomatic. However, the Board finds that his left knee disability meets the criteria for a 20 percent under Code 5258 for cartilage, semilunar, dislocated, with frequent episodes of "locking", pain and effusion into the joint. Although the clinical evidence does not show that the Veteran had a dislocated semilunar cartilage, or the removal of semilunar cartilage, he was shown by MRI in April 2010 to have a tear of the medial meniscus. Moreover, a VA examiner in April 2012 reported that the Veteran had a meniscus (semi lunar) condition with frequent episodes of locking, pain, and effusion. Also, pertinent medical records and examination reports are replete with the Veteran's complaints of left knee pain and effusion. Accordingly, the Board finds that it is more favorable to rate the Veteran's left knee disability under Diagnostic Code 5258, based on frequent episodes of pain and effusion resulting in limitation of motion of the left knee. A 20 percent rating is therefore warranted under this Code instead of the 10 percent rating formerly assigned under Diagnostic Codes 5259. This increased rating is granted throughout the duration of this appeal. 38 C.F.R. §§ 4.7, 4.71, Code 5258. Regarding the limitation of motion codes, a higher than 20 percent rating is not warranted under Code 5260 for limitation of flexion of the left knee in light of the Veteran's demonstrated ranges of motion on flexion from 90 degrees to 135 degrees. These ranges do not even satisfy the criteria under Code 5260 for a noncompensable rating (requires limitation of flexion to 60 degrees). With respect to Code 5261 for limitation of extension, in order to be entitled to a higher than 20 percent rating, the evidence has to establish limitation of extension to 20 degrees. 38 C.F.R. § 4.71a. Here, the Veteran demonstrated normal extension to 0 degrees as noted on all of his treatment records and examination reports except for one notation of extension to 20 degrees on a private treatment record dated in September 2016. Notably, also in September 2016, the Veteran demonstrated normal extension to 0 degrees at a VA examination. In short, after considering all of the evidence in its entirety, the Board finds that the single finding of 20 percent extension in September 2016 is inconsistent with all of the other range of motion findings and is not a credible finding. That is, the weight of evidence does not support a higher than 20 percent rating under Code 5261 for limitation of left knee extension. 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. Additionally, separate ratings are not warranted under both 5258 and a limitation of motion Code, as the criteria under Code 5258 contemplate decreased mobility due to pain and effusion and it would thus be pyramiding to assign separate ratings under both Codes 5258 and 5260. 38 C.F.R. § 4.14. E. Left Knee Scars Pertinent Criteria In evaluating scars, Diagnostic Code 7801 provides for a 10 percent rating for scars that are deep and nonlinear in an area or areas exceeding 6 square inches (39 square centimeters). A deep scar is defined as one associated with underlying soft tissue damage. 38 C.F.R. § 4.118, Diagnostic Code 7801 Note (1) (2017). Diagnostic Code 7802 provides that burn scars or scars due to other causes, not of the head, face or neck, that are superficial and nonlinear of an area or areas of 144 square inches (929 sq. cm.) or greater warrant a 10 percent evaluation. Diagnostic Code 7804 provides that one or two scars that are unstable or painful warrant a 10 percent evaluation. Three or four scars that are unstable or painful warrant a 20 percent evaluation. Diagnostic Code 7805 provides that any disabling affects (functional impairment) from scars not considered under the other diagnostic codes listed above should be considered under an appropriate diagnostic code. i. Restoration of 10 Percent Rating Effective April 13, 2012 In October 2009, the RO assigned the Veteran a separate 10 percent rating for his left knee scars under Code 7804 effective May 15, 2009. This rating was based on findings at a June 2009 VA examination that revealed that one out of the three left knee scars, measuring one by four centimeters, was tender to palpation. The other two scars measured .5 x 2 cms and .25 x .75 cms, and were not tender to palpation. Additional findings with respect to all three scars revealed that there was no adherence to underlying tissue, no limitation of motion or functional loss, no underlying soft tissue damage, and no skin ulceration or breakdown over the scars. The Veteran appealed the 10 percent rating and, during the pendency of this appeal, in November 2012, the RO reduced the Veteran's rating for left knee scars to a noncompensable rating effective April 13, 2012. In addressing the propriety of the reduction, as the reduction in evaluation of the service-connected left knee scars did not result in a reduction of compensation payments being made to the Veteran, a rating decision proposing the reduction was not necessary and the notice requirements of 38 C.F.R. § 3.105 (e) are not applicable here. Moreover, as this rating has been in effect for less than five years, re-examinations disclosing improvement in disabilities will warrant a rating reduction. 38 C.F.R. § 3.344 (c). Evidence considered in conjunction with this determination primarily consists of an examination report dated in April 2012. At this examination the Veteran was noted to have left knee scars that were not painful or unstable, and were not greater than 39 square centimeters. There is no notation of scar tenderness on examination. This examination was based on thorough descriptions and findings for each scar including the measurement of each scar. At a subsequent VA examination in December 2016, the Veteran was found to have three small superficial nonlinear left knee scars measuring 4.0 X 0.2 cm, 1.0 X 0.4 cm, and 1.0 X 0.4 cm, respectively. These scars were not found to be painful or unstable. The examiner also denied that there were any other pertinent physical findings, complications, conditions, signs or symptoms (such as muscle or nerve damage) associated with any of the Veteran's scars. With respect to these findings, while the Board must focus on the evidence available to the RO at the time that it effectuated the reduction when considering the propriety of a reduction, it may consider post-reduction medical evidence in the context of evaluating whether the condition had demonstrated actual improvement. Cf. Dofflemyer v. Derwinski, 2 Vet. App. 277, 281-82 (1992). The findings outlined above show that all three of the Veteran's left knee scars are asymptomatic and thus actual improvement has been shown as contemplated by 38 C.F.R. § 3.344 (c). Accordingly, a reduction in the Veteran's rating from 10 percent to noncompensable was warranted. Accordingly, the rating reduction effective April 13, 2012, was proper and the claim for restoration of a 10 percent rating for left knee scars is denied. ii. Greater than 10 Percent Rating Prior to April 13, 2012 A rating greater than 10 percent for the Veteran's left knee scars is not warranted at any point during the appeal prior to April 13, 2012. This is due to the fact that the only noted symptom for this period was tenderness of one knee scar at the June 2009 VA examination. The tender scar measured 1 x 4 cms. The other two scars, measuring .5 x 2 cms and .25 x .75 cms, respectively, were not tender to palpation. Additional findings with respect to all three scars reveal that there was no adherence to underlying tissue, no limitation of motion or functional loss, no underlying soft tissue damage, and no skin ulceration or breakdown over the scars. In light of these findings higher evaluations under Codes 7801 through 7805 are not warranted. As the weight of evidence is against a higher than 10 percent rating, the benefit of the doubt rule is inapplicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). F. Skin Disabilities Pertinent Criteria Diagnostic Code 7806 provides that dermatitis that involves at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period, is rated 10 percent disabling. Dermatitis that involves 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period, is rated 30 percent disabling. Dermatitis that involves more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period, is rated 60 percent disabling. 38 C.F.R. § 4.118, Diagnostic Code 7806. Facts The Veteran reported at a VA examination in June 2009 that symptoms of his pseudofolliculitis barbae worsen during hot weather. His reported symptoms include itching, formation of pustules, and swelling when shaving. His treatment included a shaving routine and topical ointment, but no corticosteroids or immunosuppressive drugs. The physical exam revealed darkened skin in the beard area and on both the cheeks and the neck. There were areas with papules and it was noted that the Veteran had a beard and mustache. No scars were noted. The examiner continued the existing diagnosis of pseudofolliculitis barbae and he clarified in a March 2010 addendum that the condition affected 25 percent of exposed area and five percent of total body area. The Veteran's mother reported in a June 2010 statement that ever since service she has noticed dark blotches on the Veteran's neck, chest, arms, back and legs. She said that this condition is worse in the summer months. She also stated that the Veteran avoids wearing clothing that exposes his skin. A Report of General Information in August 2010 shows that the Veteran informed VA that he had sent a claim for service connection for tinea versicolor at the same time he filed a claim for pseudofolliculitis barbae. He said that the tinea versicolor is on his neck, back, chest, stomach, hips, groin, legs, arms, and hands. He reported in a written statement (VA Form 21-4138) in August 2010 that his tinea versicolor had worsened and was spreading. The Veteran was examined by VA in September 2016 for his tinea versicolor and pseudofolliculitis barbae. The Veteran reported periodic flares of these conditions and he said that the tinea versicolor was worse in the summer months, but present all year round. He reported using topical selenium sulfide, antifungals and tea tree/coconut oils in the past without improvement. He said he limited flares of pseudofolliculitis barbae by shaving only twice a week. He also said that his tinea versicolor had worsened over the past two years. The examiner reported that the Veteran had not been treated with topical or oral medications or any other treatment in the past 12 months. He also said that the Veteran's skin conditions did not cause scarring or disfigurement. He noted that there were no benign or malignant skin neoplasms and no systemic manifestations of skin disease. He further noted that the Veteran had not had any debilitating or non debilitating episodes due to skin symptoms. He reported that the Veteran's tinea versicolor covered 5-20% of total body area and less than 5 percent of exposure areas, and his pseudofolliculitis barbae covered less than 5% of total body area and between 5 and 20% of exposed area. He went on to report that when combined, these two skin disabilities covered 20 to 40% of total body area and greater than 40 percent of exposed body area. He explained that this occurred during flares of tinea versicolor. Discussion i. Restoration of Separate 30% Rating for Tinea Versicolor The Veteran appeals an April 2014 rating decision that combined the Veteran's ratings for his service connected pseudofolliculitis barbae (rated 30 percent disabling) and tinea versicolor (rated 30 percent disabling) to a single rating of 30 percent for both disabilities. The Veteran asserts that he is entitled to two separate ratings. In September 2013, the RO afforded the Veteran notice of the proposed reduction in his skin disability rating due to combining his service connected pseudofolliculitis barbae and tinea versicolor. The RO thus satisfied the procedural requirements of 38 C.F.R. § 3.105 (e) (to include notifying the Veteran of the proposed reduction), and such requirements need not be discussed further. In general, all disabilities, including those arising from a single disease entity, are rated separately, and all disability ratings are then combined in accordance with 38 C.F.R. § 4.25. Pyramiding, the evaluation of the same disability, or the same manifestation of a disability, under different diagnostic codes, is to be avoided when rating a Veteran's service-connected disability. 38 C.F.R. § 4.14. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Here, the Veteran's skin disabilities identified as pseudofolliculitis barbae and tinea versicolor are not specifically listed under VA's Schedule for Rating Skin Disabilities. In this regard, Code 7820 provides that for infections of the skin not listed elsewhere rate as disfigurement of the head, face or neck, scars, or dermatitis, depending upon the predominant disability. The Veteran asserts that his pseudofolliculitis barbae should be rated under the criteria for scars and disfigurement (Codes 7800-7802), and he should be separately rated for his tinea versicolor under the criteria for dermatitis (Code 7806). However, the medical evidence does not show that he has disfigurement or scarring. Rather, the September 2016 VA examiner reported that the Veteran's skin conditions did not cause scarring or disfigurement of the head, face or neck. Rather, the predominant disability of both the Veteran's pseudofolliculitis and tinea versicolor involves the criteria under Code 7806 for dermatitis. This code contemplates the area of skin that is affected by the disability as well as the type of treatment being administered. Thus, to afford the Veteran separate ratings for his service connected pseudofolliculitis and tinea versicolor would violate the rule against pyramiding since it would result in rating the same manifestation of these skin disabilities. 38 C.F.R. § 4.14, Esteban v. Brown, 6 Vet App 259 (1994). Accordingly, the Board finds that VA has met its burden in justifying a reduction in his skin disability by combining his skin disabilities to a single rating consistent with the rule against pyramiding. 38 C.F.R. § 4.14; see also Brown v. Brown, 5 Vet. App. 413 (1993) (finding that the Board is required to establish, by a preponderance of the evidence and in compliance with 38 C.F.R. § 3.344, that a rating reduction is warranted). ii. Increased Rating for Skin Disabilities Based on a review of the pertinent evidence of record and resolving reasonable doubt in the Veteran's favor, the Board finds that the evidence supports a 60 percent rating for the Veteran's tinea versicolor and pseudofolliculitis barbae effective December 2016. This is based on the December 2016 VA examiner's assessment that during periods of tinea versicolor flares, both skin disabilities combine to cover an exposed area greater than 40 percent. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. Consideration has also been given to entitlement a higher than 60 percent rating; however, there is no basis upon which to assign a higher than 60 percent rating. This is so since the only schedular rating available in excess of 60 percent for skin disabilities would be a rating by analogy to Code 7817 for exfoliative dermatitis (erythroderma). Under this code, a 100 percent rating requires systemic manifestations such as fever, weight loss, and hypoproteinemia, in addition to constant or near constant systemic therapy such as therapeutic doses of corticosteroids, immunosuppressive retinoids, or PUVA or UVA treatments. The medical evidence simply does not support these criteria. 38 C.F.R. § 4.118, Code 7817. ORDER A rating greater than 10 percent for low back strain prior to September 27, 2016, is denied. An increased rating, to 20 percent, but no higher, for low back strain from September 27, 2016, is granted. An increased rating, to 20 percent, but no higher, for left ankle sprain is granted. A rating greater than 20 percent for avulsion fracture, right ankle, is denied. Restoration of a 20 percent rating for a left foot disability effective April 13, 2012, is granted. A rating greater than 20 percent for a left foot disability is denied. For the entire rating period on appeal, a 20 percent rating, but no higher, for a left knee disability is granted. Restoration of a 10 percent disability for left knee scars, effective April 13, 2012, is denied. For the period prior to April 13, 2012, a rating in excess of 10 percent for left knee scars is denied. Restoration of a 30 percent rating for tinea versicolor effective July 1, 2014 is denied. For the entire rating period on appeal, a 60 percent disability rating, but no higher, for pseudofolliculitis barbae and tinea versicolor is granted . ____________________________________________ Kristin Haddock Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs