Citation Nr: 20007971 Decision Date: 01/30/20 Archive Date: 01/30/20 DOCKET NO. 13-18 027 DATE: January 30, 2020 ORDER The 10 percent rating assigned for arthritis, right knee, in the December 5, 2001 rating decision was not clearly and unmistakably erroneous; the appeal is denied. The 10 percent rating assigned for arthritis, left knee, in the December 5, 2001 rating decision was not clearly and unmistakably erroneous; the appeal is denied. Entitlement to an increased rating of 30 percent based on impairment of flexion of the left knee prior to June 24, 2015, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a separate rating of 10 percent based on impairment of extension of the left knee prior to June 24, 2015, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 30 percent based on impairment of flexion of the right knee prior to November 16, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a separate rating of 10 percent based on impairment of extension of the right knee prior to November 16, 2016, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating in excess of 30 percent for right total knee arthroplasty from January 1, 2018, is denied. Entitlement to service connection for peripheral vascular disease (PVD) of the right leg (circulation problems) to include as due to service-connected disability is denied. Entitlement to service connection for PVD of the left leg (circulation problems) to include as due to service-connected disability is denied. REMANDED Entitlement to service connection for a bilateral foot disability including pes planus, plantar fasciitis, metatarsalgia, and tarsal tunnel syndrome (claimed as peripheral nerve damage left foot or numbness left side) including as secondary to service-connected disability remanded. FINDINGS OF FACT 1. In a December 5, 2001 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) assigned a 10 percent rating for arthritis of the right knee and arthritis of the left knee; an appeal of that decision was not initiated. 2. The December 5, 2001 rating decision was based on the record and the law which existed at the time and did not involve undebatable error which, had it not been made, would have manifestly changed the outcome of the decision. 3. Prior to June 24, 2015, left knee flexion at worse was limited to 95 degrees; but was functionally limited to zero degrees due to pain. 4. Prior to June 24, 2015, left knee extension at worse was limited to 8 degrees with pain. 5. Prior to November 16, 2016, right knee flexion at worse was limited to 95 degrees; but was functionally limited to zero degrees due to pain. 6. Prior to November 16, 2016, right knee extension at worse was limited to 8 degrees with pain. 7. From January 1, 2018, status post right knee arthroplasty resulted in flexion limited to 100 degree with mild pain; the Veteran did not have chronic residuals consisting of severe painful motion or weakness in the affected extremity. 8. PVD was not manifest during service and it is not otherwise attributable to service or etiologically related to service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for revision or reversal of the December 5, 2001 rating decision, which assigned a 10 percent rating for arthritis of the right knee on the basis of CUE have not been met. 38 C.F.R. § 3.105. 2. The criteria for revision or reversal of the December 5, 2001 rating decision, which assigned a 10 percent rating for arthritis of the left knee on the basis of CUE have not been met. 38 C.F.R. § 3.105. 3. Prior to June 24, 2015, the criteria for a 30 percent rating for left knee arthritis based on limitation of flexion are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5003-5260. 4. Prior to June 24, 2015, the criteria for a 10 percent rating for left knee arthritis based on limitation of extension are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5003-5261. 5. Prior to November 16, 2016, the criteria for a 30 percent rating for right knee arthritis based on limitation of flexion are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5003-5260. 6. Prior to November 16, 2016, the criteria for a 10 percent rating for right knee arthritis based on limitation of extension are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5003-5261. 7. From January 1, 2018, the criteria for a rating in excess of 30 percent for status post right knee arthroplasty are not met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.71a, Diagnostic Code 5055. 8. PVD of the right and left lower extremities was not incurred in or aggravated by service nor is PVD proximately due to, the result of, or aggravated by service-connected disabilities. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS 1. CUE in a December 5, 2001 rating decision The Veteran has alleged CUE in a December 5, 2001 rating decision which assigned a 10 percent rating decision for arthritis of the right knee and assigned a 10 percent rating for arthritis of the left knee. The Veteran did not appeal that decision and it became final. See 38 U.S.C. § 7105. The December 5, 2001 rating decision may be revised only upon a showing that it was clearly and unmistakably erroneous. See 38 U.S.C. §§ 5108, 5109A; 38 C.F.R. §§ 3.104, 3.105, 3.156(a); Manio v. Derwinski, 1 Vet. App. 140 (1991). Pursuant to 38 C.F.R. § 3.104(a), “[a] decision of a duly constituted rating agency... shall be final and binding... based on evidence on file at the time and shall not be subject to revision on the same factual basis.” See also 38 U.S.C. § 5108. An exception to this rule is when the VA has made a clear and unmistakable error in its decision pursuant to 38 C.F.R. § 3.105. See also 38 U.S.C. § 210(c), 7103. Under 38 C.F.R. § 3.105(a), a prior decision must be reversed or amended where evidence establishes CUE. CUE is determined by three criteria: (1) either the correct facts, as they were known at the time, were not before the adjudicator (i.e., there must be more than a simple disagreement as to how the facts were weighed or evaluated) or the statutory or regulatory provisions extant at the time were incorrectly applied; (2) the error must be undebatable and of the sort which, had it not been made, would have manifestly changed the outcome at the time it was made; and (3) a determination that there was CUE must be based on the record and law that existed at the time of the prior adjudication in question. See Damrel v. Brown, 6 Vet. App. 242 (1994); see Russell v. Principi, 3 Vet. App. 310 (1992); see also Bustos v. West, 179 F.3d 1378, 1381 (Fed. Cir. 1999) (to prove the existence of CUE as set forth in 38 C.F.R. § 3.105(a), the claimant must show that an outcome- determinative error occurred, that is, an error that would manifestly change the outcome of a prior decision). It has been held that CUE is a very specific and rare kind of ‘error.’’ It is the kind of error, of fact or of law, that when called to the attention of later reviewers compels the conclusion, to which reasonable minds could not differ, that the result would have been manifestly different but for the error. Fugo v. Brown, 6 Vet. App. 40, 43-44 (1993). The Board must emphasize that the United States Court of Appeals for Veterans Claims (Court) has consistently stressed the rigorous nature of the concept of CUE. “Clear and unmistakable error is an administrative failure to apply the correct statutory and regulatory provisions to the correct and relevant facts; it is not mere misinterpretation of facts.” Oppenheimer v. Derwinski, 1 Vet. App. 370, 372 (1991). Clear and unmistakable errors “are errors that are undebatable, so that it can be said that reasonable minds could only conclude that the original decision was fatally flawed at the time it was made.” Russell, 3 Vet. App. at 313. A disagreement with how facts were evaluated is inadequate to raise the claim of CUE. Luallen v. Brown, 8 Vet. App. 92, 95 (1995). A failure in the duty to assist does not establish CUE. See Cook v. Principi, 318 F.3d 1334 (Fed. Cir. 2002). In Cook, the United States Court of Appeals for the Federal Circuit (Federal Circuit) emphasized that a purported failure in the duty to assist cannot give rise to CUE, nor does it result in “grave procedural error” so as to vitiate the finality of a prior, final decision. In other words, to present a valid claim of CUE, the claimant cannot simply request that VA reweigh or reevaluate the evidence. Crippen v. Brown, 9 Vet. App. 412 (1996). Further, an alleged failure in the duty to assist by the RO may never form the basis of a valid claim of CUE, because it essentially is based upon evidence that was not of record at the time of the earlier rating decision. See Elkins v. Brown, 8 Vet. App. 391, 396 (1995); Caffrey v. Brown, 6 Vet. App. 377, 384 (1994). The fact that medical knowledge was not advanced to its current state may not form the basis for a valid claim of CUE, because it is premised upon facts that were not then of record. Subsequently developed evidence may not be considered in determining whether error existed in the prior decision. See Porter v. Brown, 5 Vet. App. 233, 235-36 (1993). The mere misinterpretation of facts does not constitute CUE. Thompson v. Derwinski, 1 Vet. App. 251, 253 (1991). Moreover, the error must be one that would have manifestly changed the outcome at the time it was made. Kinnaman v. Derwinski, 4 Vet. App. 20, 26 (1993). In light of the foregoing, the Veteran must argue that either the correct facts were not considered by the RO or that applicable laws and regulations were not correctly applied in the rating decision at issue. Such a determination must be based on the record and the law that existed at the time of that rating decision. Eddy v. Brown, 9 Vet. App. 52 (1996). Where evidence establishes CUE, the prior decision will be reversed or amended. 38 C.F.R. § 3.105(a). For the purpose of authorizing benefits, the rating or other adjudicative decision which constitutes a reversal of a prior decision on the grounds of CUE has the same effect as if the corrected decision had been made on the date of the reversed decision. Id. The Veteran asserts that during service, he had multiple bilateral knee symptoms which included pain, crepitus, and instability. He also had arthritis and patellar disability. As such, he asserts that more than one disability rating should have been assigned. The record to be reviewed for CUE must be based on the record and the law that existed at the time of the December 5, 2001 rating decision. 38 C.F.R. § 3.105. Disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. 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 reviewed when making disability evaluations. See generally, 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. See 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Degenerative arthritis, established by X-ray findings, will be rated on the basis of limitation of motion under the appropriated diagnostic codes for the specific joint or joints involved. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. When there is arthritis with at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. 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, a 10 percent evaluation is warranted if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and a 20 percent evaluation is authorized if there is X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups and there are occasional incapacitating exacerbations. 38 C.F.R. § 4.71(a), Diagnostic Code 5003. Diagnostic Code 5260 provides for the evaluation of limitation of flexion of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for the evaluation of limitation of extension of the knee. A noncompensable rating is warranted when leg extension is limited to 5 degrees. A 10 percent rating is warranted when it is limited to 10 degrees, a 20 percent rating is warranted when it is limited to 15 degrees, a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a 50 percent rating requires extension limited to 45 degrees. 38 C.F.R. § 4.71, Plate II, shows that normal flexion and extension of the knee is from zero degrees to 140 degrees. VA General Counsel Opinions VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 9-98 (Aug. 14, 1998) provide guidance on when separate ratings for knee disability may be assigned under the limitation of motion codes in addition to ratings under Diagnostic Code 5257 for subluxation/instability or under Diagnostic Code 5258-9 for cartilage impairment. Essentially, these opinions indicate that separate compensable ratings may be assigned when reported limitation of knee motion shown is compensable or when there is X-ray evidence of arthritis together with a finding of painful motion. 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). Under Diagnostic Code 5257, a 10 percent rating is warranted for impairment of the knee with slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for impairment of the knee with moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for impairment of the knee with severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Veteran applied for service connection for knee disabilities right after his separation from service and he was afforded a VA examination. On VA examination in September 2001, the Veteran complained of pain, weakness, stiffness, swelling, inflammation, locking, and lack of endurance. Physical examination revealed normal posture and gait. There was no limited function on standing or walking. His knee joints were within normal limits. There was no heat, redness, swelling, effusion, or drainage on either side. Range of motion testing bilaterally revealed extension of zero degrees to flexion of 110 degrees with pain at 110 degrees. There was no pain on extension. Drawer and McMurray tests were negative. Pain was the current DeLuca factor which affected range of motion for the right and left knees; the other DeLuca factors outlined above were not present. X-rays of both knees revealed arthritic changes. The examiner diagnosed bilateral knee arthritis. The examiner indicated that the limitation of function of the knees was slight. The Veteran was assigned 10 percent ratings of the knees based on the arthritis diagnosis and impairment of flexion. The RO properly applied the pertinent VA regulations as the arthritis codes provide that the arthritis should be rated based on limitation of motion codes OR if there is at least some limitation of motion, but to a degree which would be noncompensable under a limitation-of-motion code, a 10 percent rating will be assigned for each affected major joint or group of minor joints. The Veteran did not have compensable limitation of motion, but did have some loss of motion, on flexion of each knee only. So, he was properly assigned a 10 percent rating, but no higher. No instability or meniscal impairment was shown on examination. Although the Veteran indicated that a separate rating should be assigned for patellar disability, the patellar disability overlaps the arthritis disability. However, the regulations provided that the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § 4.14. A claimant may not be compensated twice for the same symptomatology as “such a result would overcompensate the claimant for the actual impairment of his earning capacity.” Brady v. Brown, 4 Vet. App. 203, 206 (1993) (interpreting 38 U.S.C. § 1155). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. If a veteran has separate and distinct manifestations attributable to the same injury, they should be compensated under different diagnostic codes. See Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). That was not the case here. The assignment of a disability rating can be grounds for CUE if it is later shown that the undisputed, contemporaneous medical evidence warranted assignment of a higher disability evaluation. Myler v. Derwinski, 1 Vet. App. 571, 574 (1991). However, an asserted failure to evaluate and interpret correctly the evidence is not clear and unmistakable error. Eddy v. Brown, 9 Vet. App. 52, 54 (1996). Likewise, the failure to fulfill the duty to assist cannot constitute CUE. Crippen. In this case, there is no contemporaneous medical evidence showing that a higher rating was warranted. The facts regarding the contemporaneous medical evidence are not undisputable. There was a basis for the assigned ratings. To the extent that the Veteran and his representative argue that the RO did not evaluate, interpret, and weigh the evidence correctly, the mere disagreement with the weighing of medical evidence does not amount to CUE. See Russell, 3. Vet. App. at 313-14. Further, even if the RO did not cite to all of the pertinent laws and regulations; this is not in itself evidence that the RO did not properly apply them. The absence of a specific reference to, or failure to cite, a controlling regulation in a rating decision does not mean it was not considered. VAOPGCPREC 6-92 at para 6 (Mar. 6, 1992). Failure to discuss regulations does not constitute CUE as there is nothing to suggest that, had there been a written discussion of such regulations, a different result would have ensued. Crippen, 9 Vet. App. at 421. In this case, the Veteran and his representative have not shown that the correct facts, as they were known at that time, were not before the adjudicator or the statutory or regulatory provisions extant at the time were incorrectly applied. The record does not establish that there was an undebatable error which, had it not been made, would have manifestly changed the outcome at the time it was made. In the absence of the kind of error of fact or law which would compel the conclusion that the result would have been manifestly different but for the error, there is simply no basis upon which to find CUE in the December 5, 2001 rating decision which assigned 10 percent ratings for each knee. Accordingly, the appeal is denied. 2. Ratings of the Bilateral Knees As noted above, disability evaluations are determined by comparing a veteran’s present symptomatology with criteria set forth in the VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4; see also 38 C.F.R. §§ 4.1, 4.3, 4.7; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where, as here, a Veteran appeals the denial of a claim for an increased disability rating for a disability for which service connection was in effect before he filed the claim for increase, the present level of disability is the primary concern, and past medical reports should not be given precedence over current medical findings. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994). Where factual findings show distinct time periods where the service-connected disability exhibits symptoms which would warrant different ratings, different or “staged” ratings may be assigned for such different periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). 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. However, the evaluation of the same “disability” or the same “manifestations” under various diagnoses is not allowed. See 38 C.F.R. § 4.14; but see Esteban v. Brown, 6 Vet. App. 259 (1994); Fanning v. Brown, 4 Vet. App. 225, 230 (1993). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32 (2011); cf. Powell v. West, 13 Vet. App. 31, 34 (1999); Hicks v. Brown, 8 Vet. App. 417, 421 (1995); Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991); Burton v. Shinseki, 25 Vet. App. 1 (2011). The Board notes that the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. The Court recently suggested that the plain language of 38 C.F.R. § 4.59 indicates that it is potentially applicable to the evaluation of musculoskeletal disabilities involving joint or periarticular pathology that are painful, whether or not evaluated under a diagnostic code predicated on range of motion measurements. See Correia v. McDonald, 28 Vet. App. 158 (2016); Southall-Norman v McDonald, 28 Vet. App. 346 (2016). In Sharp v. Shulkin, 29 Vet. App. 26, 34 (2017), the Court noted that the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from a Veteran. The rating criteria for degenerative arthritis are outlined above. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Diagnostic Code 5260 provides for the evaluation of limitation of flexion of the knee. See 38 C.F.R. § 4.71a. A noncompensable rating is warranted when leg flexion is limited to 60 degrees. A 10 percent rating is warranted when it is limited to 45 degrees, a 20 percent rating is warranted when it is limited to 30 degrees, and a 30 percent rating is warranted where flexion is limited to 15 degrees. Diagnostic Code 5261 provides for the evaluation of limitation of extension of the knee. A noncompensable rating is warranted when leg extension is limited to 5 degrees. A 10 percent rating is warranted when it is limited to 10 degrees, a 20 percent rating is warranted when it is limited to 15 degrees, a 30 percent rating requires extension limited to 20 degrees; a 40 percent rating requires extension limited to 30 degrees; and a 50 percent rating requires extension limited to 45 degrees. 38 C.F.R. § 4.71, Plate II, shows that normal flexion and extension of the knee is from zero degrees to 140 degrees. It is possible to receive separate ratings for limitation of flexion (Diagnostic Code 5260) and limitation of extension (Diagnostic Code 5261) for disability of the same joint. See VAOPGCPREC 9-2004 (Sept. 17, 2004). VA General Counsel Opinions VAOPGCPREC 23-97 (July 1, 1997) and VAOPGCPREC 9-98 (Aug. 14, 1998) provide guidance on when separate ratings for knee disability may be assigned under the limitation of motion codes in addition to ratings under Diagnostic Code 5257 for subluxation/instability or under Diagnostic Code 5258-9 for cartilage impairment. Under Diagnostic Code 5257, a 10 percent rating is warranted for impairment of the knee with slight recurrent subluxation or lateral instability; a 20 percent rating is warranted for impairment of the knee with moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for impairment of the knee with severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5262, malunion impairment of the tibia or fibula with a slight knee or ankle disability will be assigned a 10 percent rating, moderate knee or ankle disability will be assigned a 20 percent disability rating, marked knee or ankle disability will be assigned a 30 percent disability rating, and non-union of the tibia and fibula with loose motion, requiring a brace, will be assigned a 40 percent disability rating. 38 C.F.R. § 4.71a, Diagnostic Code 5262. Under Diagnostic Code 5258, a 20 percent disability rating is warranted when there is dislocation of the semilunar cartilage with frequent episodes of locking, pain, and effusion into the joint. The VA Office of General Counsel has stated that Diagnostic Code 5259, removal of semilunar cartilage, may result in complications producing loss of motion. As such, limitation of motion is a relevant consideration under Diagnostic Code 5259. VAOPGCPREC 9-98 (Aug. 14, 1998). Although the Veteran was noted to have meniscus issues in the past, he does not have current symptoms. Any pain of the left knee has been compensated under the current rating, as noted above. A duplicate rating for pain would be pyramiding which is impermissible. Diagnostic Code 5055 provides criteria for evaluating impairment arising from the prosthetic replacement of a knee joint. For one year following the implantation of a knee prosthesis, a 100 percent disability rating is assigned. Thereafter, the minimum disability rating which may be assigned, post-knee replacement is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. A 60 percent disability rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Id. With intermediate degrees of residual weakness, pain or limitation of motion, adjudicators are instructed to rate by analogy to Diagnostic Codes 5256 (knee ankylosis), 5261 (limitation of leg extension), or 5262 (impairment of the tibia and fibula). Id. Diagnostic Code 5256 pertains to ankylosis of the knee. A 30 percent rating is assignable for ankylosis of the knee at a favorable ankle in full extension, or in slight flexion between 0 degrees and 10 degrees. A 40 percent rating is assignable for ankylosis of the knee in flexion between 10 degrees and 20 degrees. A 50 percent rating is assignable for ankylosis of the knee in flexion between 20 degrees and 45 degrees. A 60 percent rating is assignable for extremely unfavorable ankylosis of the knee in flexion at an angle of 45 degrees or more. A schedular rating greater than 60 percent is barred. That is, the combined rating for disabilities of an extremity shall not exceed the rating for the amputation at the elective level, were amputation to be performed. See 38 C.F.R. § 4.68, Amputation Rule. An above the knee amputation, not to include a thigh amputation, is rated 60 percent disabling. See 38 C.F.R. § 4.71a, Diagnostic Codes 5162, 5163. Accordingly, the Veteran may not receive a combined rating greater than 60 percent for either knee. In June 2011, the Veteran was afforded a VA examination. Active range of motion of the bilateral knees measured times three with a goniometer was as follows: Flexion of both knees is 0 to 110 degrees with pain throughout and extension to 0 degrees. With three repetitions, the DeLuca factors were further limiting, but this was not noted in terms of degrees. There was no anterior, posterior, or lateral instability. There were no popliteal masses, and there negative McMurray sign bilaterally. There was +1 crepitus on the right and no crepitus on the left. The diagnosis was severe bilateral degenerative joint disease of the knees. Thereafter, VA medical records include x-rays confirming arthritic change. August 2012 records showed that the Veteran was able to ambulate 1-2 blocks only due to pain in both knees and also due to PVD. Flexion was to 115 out of 140 degrees with no warmth or swelling. There was no objective evidence of instability or subluxation. The Veteran was subsequently measured for new braces. In October 2012, the Veteran was afforded another VA examination. Active range of motion of the bilateral knees measured times 3 with a goniometer was as follows: right knee flexion ended at 95 degrees with objective evidence of painful motion beginning at 0 degrees, right knee extension ended at 0 degrees with no objective evidence of painful motion. Left knee flexion ended at 95 degrees with objective evidence of painful motion beginning at 0 degrees, left knee extension ended at 0 degrees with no objective evidence of painful motion. With 3 repetitions, there was no change in the above measurements. The Veteran did not have additional limitation in range of motion of the knee and lower leg following repetitive use testing. Functional loss was due to less movement than normal and pain on movement bilaterally. The Veteran had no tenderness to either knee on palpation. He had normal strength of knee flexion and extension bilaterally. There was no anterior, posterior, or lateral instability of either knee. There was no evidence of recurrent patellar subluxation or dislocation. There was no evidence of shin splints, stress fracture, chronic exertional compartment syndrome, acquired traumatic genu recurvatum, or leg length discrepancy bilaterally. The Veteran used braces on a regular basis and a cane on a regular basis because of his knees. Functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. Bilateral knee films done in December 2009 revealed bilateral degenerative joint disease with tricompartmental joint space narrowing bilaterally. There was no radiographic evidence of bilateral patellar subluxation. The Veteran worked as a veterans’ service representative. It was a sedentary job and he mostly worked at a computer. He stated that he could do his job, which was sedentary, despite his knee pain, but he would not be unable work at physical labor because of his knee condition. The examiner agreed with this assessment. The diagnosis was degenerative joint disease of both knees. A May 2013 electronic mail from a VA examiner noted that following an April 2013 treatment, the knee orthoses for which the Veteran was fitted in September 2012 was for the purpose of unloading the medial joint of the knees as he had moderately advanced degenerative joint disease changes on the medial joint on the x-rays and to relieve some the pain on standing and walking. The orthoses also provided some knee support/stability, but primarily was for pain relief to allow the Veteran to walk farther. There was no joint instability when he was examined in August 2012. In May 2013, a coworker of the Veteran also indicated that the Veteran’s knee problems limited his physical abilities and that he used a cane. Another coworker stated that the knee disabilities caused the Veteran to fall. A later May 2013 clinical note reflects that the Veteran was ambulatory with a cane. On the right, he had motion from 5 to 100 degrees. On the left, motion was 8 to 104 degrees. There was tenderness on medial and lateral joint lines, medial femoral condyle and with compression of patellofemoral joint. There was negative anterior and posterior drawer’s and Lachman’s test as well as McMurray’s test. There was pain on the medial knee with varus stress test. There was no laxity. Strength was 4+/5. There were no surgery scars noted on the knees. There was gait dysfunction. In October 2013, the Veteran was afforded a VA examination. Range of motion of both knees was zero to 110 degrees with no pain. Repetitive testing did not change the range of motion. Although range of motion testing did not elicit pain, the examiner indicated that the Veteran demonstrated bilaterally, pain on movement; disturbance of locomotion; and interference with sitting, standing and weight-bearing. Muscle strength was normal. Stability testing was normal. There was no recurrent patellar subluxation or dislocation. The Veteran never had had “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran had not had any meniscal conditions or surgical procedures for a meniscal condition. The Veteran had constantly used a cane and occasionally a brace. Arthritis of the knees was noted. October 2014 VA records show that the Veteran was seen with complaints of knee pain. Active range of motion bilaterally was zero to 115 degrees. Knee replacement was discussed. The next month, flexion was limited to 100 degrees. The Veteran subsequently had a left knee injection for pain. On June 24, 2015, the Veteran underwent left knee replacement. The Veteran was then assigned a 100 percent rating from the date of the surgery until January 1, 2018, when a 30 percent rating was assigned. On November 16, 2016, the Veteran underwent a right knee replacement. The Veteran was then assigned a 100 percent rating from the date of the surgery until January 1, 2018, when a 30 percent rating was assigned. In February 2018, the Veteran was afforded a VA examination. Range of motion testing bilaterally showed full extension at zero degrees to 100 degrees of flexion. There was no additional functional loss or range of motion after three repetitions. There was left knee crepitus. There was objective evidence of mild sub patellar pain. There was evidence of pain with weight bearing. Pain was noted on examination but did not result in/cause functional loss. Pain, weakness, fatigability or incoordination for both knees did not significantly limit functional ability with repeated use over a period of time. Strength was normal in both knees. There was no muscle atrophy. There was no ankylosis of either knee. There was no recurrent subluxation or instability of either knee. The Veteran did not now have and had not ever had recurrent patellar dislocation, “shin splints” (medial tibial stress syndrome), stress fractures, chronic exertional compartment syndrome or any other tibial and/or fibular impairment. The Veteran did not now have and had not ever had a meniscus (semilunar cartilage) condition. Post right knee and left knee replacement, the Veteran’s symptoms were mild subpatellar tenderness and limited range of motion. The Veteran regularly used a cane. Bilaterally, the functioning was not so diminished that amputation with prosthesis would equally serve the Veteran. With regard to functional impairment, the Veteran could not lift anything heavy and could not stand or walk any prolonged length of time. The examiner stated that sedentary work would have mild to no effects on the Veteran’s total knee replacements as he would not need to do any heavy lifting or prolonged walking or standing. a. Entitlement to an increased rating for arthritis of the left knee rated as 10 percent disabling prior to June 24, 2015 Prior to June 24, 2015, the Veteran has been assigned a 10 percent rating based on impairment of flexion. Prior to June 24, 2015, flexion at most was limited to 95 degrees. However, considering the DeLuca factors and Correia, the Veteran demonstrated pain from zero degrees throughout the entire motion of the knee on flexion. Thus, the maximum 30 percent rating based on functional impairment on flexion under Diagnostic Code 5260 is warranted. A higher rating would necessitate ankylosis which the Veteran did not have. Extension at worse was limited to 8 degrees with pain. A separate 10 percent rating based on impairment of extension including pain under Diagnostic Code 5261 is warranted. A rating higher than 10 percent is not warranted because extension was not functionally limited to 15 degrees or more. The Veteran did not additionally have recurrent subluxation or lateral instability, meniscus impairment, impairment of the tibia or fibula, or ankylosis of the knee. The Board has considered the lay evidence of record and treatise submissions, but none of these establish a higher level of impairment as such was not objectively shown on testing or in the medical records. b. Entitlement to an increased rating for arthritis of the right knee in excess of 10 percent disabling prior to November 16, 2016 Prior to November 16, 2016, the Veteran has been assigned a 10 percent rating based on impairment of flexion. Prior to November 16, 2016, flexion at most was limited to 95 degrees. However, considering the DeLuca factors and Correia, the Veteran demonstrated pain from zero degrees throughout the entire motion of the knee on flexion. Thus, the maximum 30 percent rating based on functional impairment on flexion under Diagnostic Code 5260 is warranted. A higher rating would necessitate ankylosis which the Veteran did not have. Extension at worse was limited to 8 degrees with pain. A separate 10 percent rating based on impairment of extension including pain under Diagnostic Code 5261 is warranted. A rating higher than 10 percent is not warranted because extension was not functionally limited to 15 degrees or more. The Veteran did not additionally have recurrent subluxation or lateral instability, meniscus impairment, impairment of the tibia or fibula, or ankylosis of the knee. The Board has considered the lay evidence of record and treatise submissions, but none of these establish a higher level of impairment as such was not objectively shown on testing or in the medical records. c. Entitlement to an increased rating for arthritis of the right knee in excess of 30 percent disabling from January 1, 2018. From January 1, 2018, a 30 percent rating has been assigned under Diagnostic Code 5055 based on his residuals following knee replacement. As noted, 30 percent is the minimum rating. Following the surgery, flexion was still limited to 100 degrees, but extension was full. The DeLuca factors did not result in additional loss, other than the impaired flexion with mild pain. The Veteran did not have chronic residuals consisting of severe painful motion or weakness in the affected extremity. If the Veteran was alternatively rated based on the flexion, he would be assigned a 10 percent rating based on the painful flexion. The Veteran did not additionally have impaired extension, recurrent subluxation or lateral instability, meniscus impairment, impairment of the tibia or fibula, or ankylosis of the knee. As such, a rating in excess of 30 percent is not warranted for this time period. 3. Service Connection for PVD of the Lower Extremities Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones (Wayne L.) v. Brown, 7 Vet. App. 134 (1994). There must be competent evidence of a current disability; evidence of a service-connected disability; and competent evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). With regard to the matter of establishing service connection for a disability on a secondary basis, the Court has held that there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Reasonable doubt concerning any matter material to the determination is resolved in the Veteran’s favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The service treatment records (STRs) do not reflect complaints, findings, treatment, or diagnosis of PVD. The Veteran had chest pain during service and has been service-connected, in pertinent part, for his knees, hypertension, and coronary artery disease (CAD). PVD was initially diagnosed in 2008, approximately seven years after the Veteran separated from service. In November 2012, a VA examiner stated, based on history and physical examination as well as review of the file and a review of the current evidence-based medical literature, that the Veteran’s PVD is not attributable to chest pain. This includes chest pain which is associated with sinus bradycardia and borderline testing noted on an inservice EKG. The examiner also opined that it is less likely as not caused by or aggravated by the results of his service-connected arthritis right and left knee. The examiner indicated that he had been unable to locate any evidence-based medical literature which primarily attributes a PVD condition to arthritis of the knees. The examiner knew of no evidence-based medicine source which substantiates that PVD can be aggravated beyond its natural progression by service-connected arthritis of either or both knees. A December 2016 VA examination confirmed that the Veteran has PVD of the bilateral lower extremities. The VA examiner provided a medical opinion which was updated in January 2017. The examiner opined that there is no evidence in the STRs to indicate that PVD had its clinical onset during service, within one year of service or that it is related to any inservice disease, event or injury. The examiner further indicated that while primary hypertension may be considered to be a risk factor for heart disease and PVD, as there are many risk factors for the same including age, obesity, hyperlipidemia, smoking, sex, family history, and poor diet, after review of the research criteria there is no direct causal relationship between hypertension and heart disease, and his PVD condition. The examiner stated there is no documentation in the STRs to suggest that the PVD condition was aggravated by primary hypertension. After a review of the research literature, the examiner stated that hypertension does not cause PVD. Additionally, the examiner noted that the Veteran was taking amlodipine, losartan and HCTZ all for “controlled hypertension.” It was noted that the Veteran smoked one pack per day for 28 years and is overweight with high cholesterol diagnosed in 2008. All three of these said factors are known to be associated with PVD. Hypertension may also have a correlational relationship, but there is no direct causal link between hypertension and PVD. The examiner indicated that there was no causal relationship based on aggravation either. In April 2017, another VA medical opinion clarified that PVD is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran’s service-connected CAD. The examiner explained that the coronary arteries are small arteries within the heart. The peripheral vascular system is the vasculature within the lower extremities. After a review of the research literature, the examiner stated that there may be some correlation between plaque in the coronary blood vessels (CAD) and the plaque in the peripheral vascular system, but there is no causal link between CAD and PVD. The risk factors for both CAD and PVD include advanced age, smoking, and diabetes. After a review of the research literature, the examiner indicated that the coronary arteries lie within the heart muscle itself and the blood vessels in the peripheral vascular system are within the lower extremities for the PVD for this Veteran. They are separate from each other and as there is no causal relationship between the two. Risk factors for both CAD and PVD include advanced age, smoking, diabetes, hypertension and hyperlipidemia. The aggravating factors for PVD most likely for this Veteran are his smoking history and hyperlipidemia whether it be diet or genetic oriented and his advanced age. A subsequent August 2017 VA medical opinion again indicates that there is no relationship between the Veteran’s total knee replacements and PVD or the development of PVD. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In this case, the medical opinions are based on a review of the record and medical literature/principles. The Board therefore attaches significant probative value to the opinions, and the most probative value in this case. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Although the Veteran has submitted his opinion and treatise evidence, the medical opinions are submitted by medical professionals based on the specifics of the Veteran’s case and are more probative. To the extent that the Veteran’s opinion is contrary to the medical opinions, the medical opinions considered the pertinent evidence of record, considered the Veteran’s contentions, and concluded that there is no relationship between PVD and service, and between PVD and his service-connected disabilities. See id.; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Thus, the Board finds the most probative evidence of record shows that the Veteran’s PVD is not attributable to service or to service-connected disability. The evidence in this case is not so evenly balanced so as to allow application of the benefit-of-the-doubt rule as required by law and VA regulations. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The preponderance is against the Veteran’s claim, and it must be denied. REASONS FOR REMAND 4. Entitlement to service connection for a bilateral foot disability including pes planus, plantar fasciitis, metatarsalgia, and tarsal tunnel syndrome (claimed as peripheral nerve damage left foot or numbness left side) including as secondary to service-connected disability is remanded. The Veteran has been diagnosed with bilateral foot disabilities and medical opinions have been obtained. However, the medical opinion pertaining to tarsal tunnel syndrome dated in June 2017 is inadequate. The examiner opined that there was no direct causal connection between the Veteran’s knee disabilities and his tarsal tunnel syndrome. However, with regard to aggravation, the examiner stated that aggravation of the tarsal tunnel syndrome would consist of increased compression on the posterior tibial nerve which is unable to be assessed in this Veteran’s STRs. There is no documentation of tarsal tunnel syndrome symptoms in the STRs. The Board notes that there is no requirement that there be an inservice diagnosis of tarsal tunnel syndrome with regard to either direct or secondary service connection, or, as pertinent here, for secondary service connection based on aggravation. As such, a medical addendum is needed. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bilateral tarsal tunnel syndrome is at least as likely as not proximately due to service-connected knee disabilities; or aggravated beyond its natural progression by service-connected knee disabilities. The examiner should note that there is no requirement that there be an inservice diagnosis of tarsal tunnel syndrome with regard to either direct or secondary service connection so a lack of a diagnosis in the STRs is not dispositive. (Continued on the next page)   A complete explanation should be provided for all expressed opinions. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Connolly, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.