Citation Nr: 20023091 Decision Date: 04/03/20 Archive Date: 04/03/20 DOCKET NO. 17-29 255 DATE: April 3, 2020 ORDER Entitlement to a compensable rating for service-connected erectile dysfunction is denied. Entitlement to a rating in excess of 10 percent for service-connected multilevel degenerative disc disease, lumbar spine, is denied. Entitlement to a compensable rating for service-connected gout, bilateral great toes, is denied. Entitlement to a rating in excess of 10 percent for right knee status post partial knee medial meniscectomy with residual scarring based on limitation of painful motion is denied. Entitlement to a separate rating of 10 percent, but not higher, for right knee status post partial knee medial meniscectomy is granted. REMANDED Entitlement to service connection for a neck condition is remanded. FINDINGS OF FACT 1. During the entire period on appeal the Veteran's erectile dysfunction has resulted in a loss of erectile power; but not with penile deformity. 2. During the period on appeal the Veteran's lumbar spine disability was manifested by forward flexion of the thoracolumbar spine greater than to 70 degrees but not greater than 85 degrees; with a combined range of motion of the thoracolumbar spine greater than to 155 degrees but not greater than 235 degrees, with no muscle spasms or guarding resulting in an abnormal gait or abnormal contour. 3. During the period on appeal the Veteran’s gout did not show objective evidence of gout along with any limitation of motion of the joint. 4. During the entire period on appeal the right knee status post partial knee medial meniscectomy with residual scarring and painful motion, did not manifest to a limitation of flexion of 30 degrees of less, or extension of 15 degrees or less. 5. The Veteran underwent a right knee meniscectomy in 2009 that continued to contribute to pain on motion but not with frequent episodes of locking, pain, and effusion into the joint. CONCLUSIONS OF LAW 1. The criteria for a compensable increased rating for erectile dysfunction have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.115b, Diagnostic Code 7599-7522 (2019). 2. The criteria for an evaluation in excess of 10 percent for a lumbar strain have not been met. 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 (2019). 3. The criteria for a compensable increased rating for gout have not been met. 38 U.S.C. §§ 1155, 5107 (2012), 38 C.F.R. §§ 4.1, 4.7, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5017, 5271 (2019). 4. The criteria for a rating in excess of 10 percent for service-connected residuals of right knee medial meniscectomy based on limitation of motion have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.71a, Diagnostic Code 5260 (2019). 5. The criteria for a separate rating of 10 percent, but not higher, for residuals of right knee medial meniscectomy have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321(b)(1), 4.1, 4.3, 4.7, 4.10; 4.71a, Diagnostic Code 5259 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty for training in the United States Army from February to August 1990, and on active duty from May 2003 to April 2004, from June 2006 to October 2007, and from August 2008 to September 2010 including service in Southwest Asia. He was awarded the Bronze Star Medal. He had additional service in the National Guard through at least 2016. These matters are before the Board of Veterans’ Appeals (Board) on appeal from an October 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. A videoconference hearing was held before the undersigned Veterans Law Judge in December 2019. The transcript is of record. Increased Rating Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). 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). Here, staged ratings will be considered and discussed, as warranted. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Moreover, joint testing is to be conducted 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. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). Erectile Dysfunction The Veteran contends that his erectile dysfunction warrants a compensable rating. The Veteran contends ongoing symptomology and use of medication. The Veteran 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). As such, these statements are entitled to probative value as to the severity of his erectile dysfunction during the period on appeal. The Board finds that the preponderance of the evidence is against finding that a compensable rating for the Veteran's erectile dysfunction is warranted. The Veteran's erectile dysfunction is rated as noncompensable under 38 C.F.R. § 4.115b, Diagnostic Code 7599-7522. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the rating assigned. 38 C.F.R. § 4.27. There is no specific disability rating for erectile dysfunction. The closest analogous code is 38 C.F.R. § 4.115b, Diagnostic Code 7522, which rates deformity of the penis with loss of erectile power. "Deformity" under DC 7522 means "a distortion of the penis, either internal or external," based on the ordinary meaning of the term as gleaned from Dorland's Illustrated Medical Dictionary. Williams v. Wilkie, 2018 U.S. App. Vet. Claims LEXIS 1037. The Board can find no other Diagnostic Code provision that would be more appropriate in rating the Veteran's disability. There is no evidence that he has had removal of half or more of his penis, that there is internal deformity such as nerve or other structural abnormality, or that glans have been removed, such that would warrant consideration under Diagnostic Codes 7520 or 7521, respectively. Therefore, Diagnostic Code 7522 is most appropriate to rate this disability. Pursuant to Diagnostic Code 7522, two distinct elements are required for a compensable, 20 percent, disability rating: penile deformity and loss of erectile power. As the Veteran is not shown to have both penile deformity and loss of erectile power, the Board finds that a compensable evaluation for erectile dysfunction is not warranted. The Veteran was afforded a VA examination in September 2016. The examiner noted a diagnosis of erectile dysfunction, that was diagnosed in 2007. The examiner noted that the Veteran began experiencing difficulty due to his antihypertensive condition. The Veteran indicated that he began Levitra in 2010 and at the time of the examination was taking Viagra with a favorable response. There was no history of an injury, trauma or surgery to the genitourinary system. The examiner noted his treatment plan included continuous medication for the diagnosed condition. The Veteran did not have a renal dysfunction, orchiectomy or voiding dysfunction. The etiology of the Veteran's erectile dysfunction was long standing hypertension and its treatment. The Veteran did not have retrograde ejaculation, history of reproductive organ infections, chronic epididymitis, epididymo-orchitis or orchitis. The Veteran’s physical exam provided normal results, but the prostate was not tested since it was not relevant to the examination. VA treatment records have been associated with the claims file and note ongoing reports of erectile dysfunction and continued use of medication. Based on the lay and medical evidence of record the Board finds that the Veteran's erectile dysfunction does not more nearly approximate the level of severity contemplated by an increased compensable rating. The Board notes the Veteran's ongoing erectile dysfunction and use of medication. The Veteran is competent to testify to such lay observable symptomatology. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). However, such lay evidence in this case, even when accepted as accurate, does not establish a level of disability contemplated by a higher evaluation. The evidence of record supports a noncompensable rating is warranted for the entire period on appeal. The VA examination in September 2016 noted organic erectile dysfunction due to long standing hypertension and its treatment. The record demonstrates an ongoing diagnosis of erectile dysfunction, without evidence of deformity of the penis. In order to warrant a compensable disability rating there must be evidence of a penile deformity, which here there is none. During the Board hearing, the Veteran reported that he has a penile deformity during erections. Although the 2016 examiner found a normal physical status, the examination report did not mention, and it is unlikely that the examination was performed during an erection. However, the Veteran did not report any such deformity at the time. That he can achieve erections is contrary to the service-connected disability of an inability to achieve erections. Therefore, the Board places low credible weight on the report of deformity. The Veteran is being separately compensated for the loss of use of a creative organ or, in this case his difficulties obtaining and maintaining an erection caused by medications. As such the Board finds that the Veteran is not entitled to a compensable rating for erectile dysfunction. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding a compensable rating for the Veteran's service-connected erectile dysfunction and is not warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. Lumbar Spine Disabilities of the spine are rated under the General Rating Formula for Diseases and Injuries of the Spine (General Formula) (for DCs 5235 to 5243, unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes). With or without symptoms such as pain (whether or not it radiates), stiffness, or aching in the area of the spine affected by residuals of injury or disease, the Formula provides for ratings as follows: 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 body height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or a combined range of motion of the thoracolumbar spine greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. Rating Formula for Diseases and Injuries of the Spine, Diagnostic Codes 5237, 5242, Note 1. 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 diagnostic code. Note 2 states that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The 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 of the thoracolumbar spine is 240 degrees. 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. Diagnostic Code 5243 provides for rating intervertebral disc syndrome (IVDS) under the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.71a, Diagnostic Code 5243. The Formula for Rating IVDS based on Incapacitating Episodes provides ratings for incapacitating episodes as follows: having a total duration of at least 6 weeks during the past 12 months (60 percent); having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months (40 percent); having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months (20 percent); and having a total duration of at least one week but less than 2 weeks during the past 12 months (10 percent). 38 C.F.R. § 4.71a. 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. The Veteran contends that his assigned disability rating does not adequately contemplate the severity of his condition. The Veteran attended a VA examination in September 2016. The Veteran reported pain at 7/10 on the pain scale. The Veteran indicated that he did not have any flareups of the spine. The Veteran how ever did report functional loss or functional impairment due to having limitation with prolonged sitting or bending and lifting. Range of motion testing revealed forward flexion of 70 degrees; extension and right lateral and left lateral flexion were 15 degrees; and right lateral and left lateral rotation were 20 degrees. The Veteran’s combined range of motion was 155. There was no evidence of pain with weightbearing. There was evidence of localized tenderness at the lower lumbar spine. The Veteran was able to perform repetitive use testing with no additional loss of function after three repetitions. There was no guarding or muscle spasms. The Veteran did not have muscle atrophy or signs or symptoms of radiculopathy. The Veteran did not have ankylosis of the spine or IVDS. And the Veteran did not have a thoracic vertebral fracture with loss of 50 percent or more of his height. The Veteran denied radiculopathy. The examiner concluded that the Veteran's back disability would impact his ability to work due to the issues mentioned above. VA treatment records have been associated with the claims file and note ongoing reports of low back pain which at times limited movement and decreased activity. Based on the lay and medical evidence of record the Board finds that the Veteran's lumbar spine disability does not more nearly approximate the level of severity contemplated by an increased 20 percent rating during the period on appeal. The Board considered the Veteran's contentions regarding his ongoing symptomology, increased pain and limited movement of his lumbar spine disability. However, such lay evidence in this case, even when accepted as accurate does not establish a level of disability contemplated by a higher evaluation. Under Diagnostic Code 5237, an increased 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or combined range of motion of the thoracolumbar spine greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal contour such as scoliosis. There is no competent evidence of forward flexion between 30 and 60 degrees, and the combined range of motion of the Veteran's thoracolumbar spine was greater than 120 degrees. The VA examiner in September 2016 noted forward flexion to 70 degrees, with evidence of painful motion at 70 degrees, the forward flexion and at 15 degrees the extension; and a combined range of motion of the thoracolumbar spine to 155 degrees. The examination noted no guarding or muscle spasms. The Board finds that the September 2016 VA examination is entitled to significant probative weight. The Board finds that during this period on appeal the Veteran's symptoms most closely approximated the criteria for a 10 percent rating. As such an increased 20 percent rating is not warranted for the period on appeal. Regarding assigning a higher disability rating according to 38 C.F.R. §§ 4.40, 4.45, 4.59 the Board finds that painful motion is already contemplated by the currently assigned 10 percent rating based on limited motion. In addition, as shown above, even considering the additional functional loss or limitation of motion due to symptoms such as pain, weakness, weakened movement, excess fatigability, or incoordination, beyond that noted by the VA examiner a higher disability rating is not warranted. Therefore, the Board concludes that the greater weight of evidence is against assigning higher ratings under Deluca. No additional higher or alternative ratings under different Diagnostic Codes for the spine can be applied for this period. As noted above Diagnostic Code 5237 provides for rating disabilities of the spine under either the General Rating Formula for Diseases and Injuries of the Spine, or under the Formula for Rating IVDS, whichever results in the higher rating. However, there is no evidence of incapacitating episodes as contemplated by the regulation, and neither the lay nor medical evidence suggests that there has been physician prescribed bed rest. In light of the lack of evidence demonstrating any episodes requiring bed rest prescribed by a physician and treatment by a physician for intervertebral disc syndrome; and in light of the lack any assertion on the part of the Veteran that the criteria for incapacitating episodes have been met, the Board finds that a higher rating under the formula for rating intervertebral disc syndrome based on incapacitating episodes is not warranted during this period. All potentially applicable Diagnostic Codes have been considered. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). The preponderance of the evidence is against finding an increased rating in excess of 10 percent for the Veteran's service-connected lumbar spine disability. Therefore, an increased rating is not warranted. As such, the benefit-of-the-doubt doctrine is inapplicable. 38 C.F.R. § 4.3. Gout, Bilateral Great Toes The Veteran is seeking an increased rating for his gout of the bilateral great toes; the Veteran's disability has been assigned a rating under 38 C.F.R. § 4.71a, Diagnostic Code (DC) 5017 respectively. Pursuant to the rating criteria associated with DC 5017, gout is rated under DC 5002, as for rheumatoid arthritis. For an active disease process, DC 5002 provides for assignment of a 10 percent rating is warranted for gout if there is objective evidence of gout along with any limitation of motion of the joint. A 20 percent rating is provided for one or two exacerbations a year in a well-established diagnosis. A 40 percent rating is provided for symptom combinations productive of definite impairment of health objectively supported by examination findings or incapacitating exacerbations occurring 3 or more times a year. A 60 percent rating is warranted for symptoms that are less than criteria for 100 percent rating, but with weight loss and anemia, that are productive of severe impairment of health or severely incapacitating exacerbations occurring 4 or more times a year or a lesser number of over prolonged periods. Finally, a 100 percent rating is warranted for constitutional manifestations associated with active joint involvement that is totally incapacitating. 38 C.F.R. § 4.71a, DC 5002. DC 5002 further provides that for chronic residuals such as limitation of motion or ankylosis, favorable or unfavorable, the disability is rated under the appropriate diagnostic codes for the specific joints involved. Where, however, the limitation of motion of the specific joint or joints involved is noncompensable under the codes, a rating of 10 percent is for application for each such major joint or group of joints affected by limitation of motion, to be combined, not added under DC 5002. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. The Note to DC 5002 instructs that the ratings for the active process will not be combined with the residual ratings for limitation of motion or ankyloses. The higher rating should be assigned. Id. The Veteran was afforded a VA examination in April 2019. The examiner noted that the Veteran had a diagnosis of gout. The examiner noted that the Veteran had a long history of gout. The Veteran initially had flareups 6 times a year, but the Veteran had no flareups of gout in the greater toes for years. At the time of the examination the Veteran had no flareups, no joint pain, and was compliant with his medication. The Veteran required continuous use of medication. The Veteran did not have any weight loss or anemia due to the condition. The Veteran did have pain with or without joint movement in his left knee, foot and toes. The Veteran did not have any limitation of joint movement and no joint deformities. The Veteran did not have exacerbations which were incapacitating. The Veteran’s condition was not associated with active joint involvement which were totally incapacitating. The Veteran did not use any assistive devices. The examiner also noted that the Veteran’s condition did not affect his ability to work. The Board has carefully considered all the evidence and potentially applicable diagnostic codes and finds that the disability picture of the Veteran's bilateral greater toes disability does not more nearly approximate the rating criteria of a higher disability level, of the 10 percent compensable rating. The evidence does not show that the Veteran's symptoms meet the criteria for a 10 percent disability rating under DC 5017. The evidence of record does not establish that the Veteran experiences any limitation of motion of the joint, although objective evidence indicates the Veteran has gout. At the Veteran’s April 2019 examination, the Veteran had no flareups for years, no joint pain and was compliant with his medication. Therefore, the currently assigned noncompensable rating contemplates the Veteran's disability. Accordingly, entitlement to a compensable rating for gout of the bilateral toes is not warranted. In addition, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable because the preponderance of the evidence is against the claim for a higher rating. 38 C.F.R. §§ 4.7, 4.21. Right Knee Disability of the musculoskeletal system is primarily the inability, due to damage or infection of parts of the musculoskeletal system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. The functional loss may be due to absence of part, or all, of the necessary bones, joints, and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). VA General Counsel has 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 09-04; 69 Fed. Reg. 59,990. The basis for the opinion is that the knee has separate planes of movement, each of which is potentially compensable. Id. Normal ranges of motion of the knee are to 0 degrees in extension and to 140 degrees in flexion. 38 C.F.R. § 4.71, Plate II. DC 5260 provides ratings based on limitation of flexion of the leg. Flexion of the leg limited to 60 degrees is rated noncompensable; flexion limited to 45 degrees is rated 10 percent; flexion limited to 16 to 30 degrees is rated 20 percent; and flexion limited to 15 degrees is rated 30 percent. 38 C.F.R. § 4.71a. DC 5261 provides ratings based on limitation of extension of the leg. Extension of the leg limited to 5 degrees is rated noncompensable; extension limited to 10 degrees is rated 10 percent; extension limited to 15 degrees is rated 20 percent; extension limited to 20 degrees is rated 30 percent; extension limited to 30 degrees is rated 40 percent; and extension limited to 45 degrees is rated 50 percent. 38 C.F.R. § 4.71a. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). Under the criteria for impairment of the knee other than ankylosis, 10, 20, and 30 percent evaluations are assigned for slight, moderate, and severe recurrent subluxation or instability, respectively. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Arthritis manifested by limitation of motion and instability of the knee are two separate disabilities, and a veteran may be rated separately for these symptoms. See VAOPGCPREC 23-97; 62 Fed. Reg. 63,604 (when a claimant has arthritis and is rated under instability of the knee, those two disabilities may be rated separately under 38 C.F.R. § 4.71a Diagnostic Codes 5003 or 5010 and Diagnostic Code 5257.). Under Diagnostic Code 5258, a 20 percent rating is warranted for a dislocated semilunar cartilage, with frequent episodes of locking, pain, and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, a 10 percent disability rating is warranted for a symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Evaluation of a knee disability for limitation motion under 38 C.F.R. § 4.71a , Diagnostic Codes 5260 or 5261 does not preclude, as a matter of law, separate evaluation of a meniscal disability of the same knee under 38 C.F.R. § 4.71a , Diagnostic Code 5259. Nor does evaluation of a meniscal disability under § 4.71a, Diagnostic Code 5259 preclude, as a matter of law, separate evaluation of a different disability of the same knee under § 4.71a, Diagnostic Code 5260 or 5261. See Lyles v Shulkin, 29 Vet. App. 107 (2017). The RO received the Veteran’s claim for an increased rating for the right knee in July 2016. At that time, the right knee was rated as 10 percent disabling for residuals of a meniscectomy under Diagnostic Code 6261 for painful motion, citing a previous VA examination report dated in December 2011. It is not clear why the RO selected the criteria for limitation of extension. In a July 2015 VA treatment note, the Veteran reported that his pain was a 9/10. The clinician noted that the Veteran had meniscal surgery on his right knee in the past. See April 2018 Capri, p.5. In June 2016, the Veteran was diagnosed with knee pain. The Veteran was given in orthotic/prosthetic device for his knees. The Veteran reported that his right knee had swelled after exercising and that the pain was sharp. The Veteran indicated that the pain was worse when jogging and prolonged standing. See April 2018 Capri, p.2-3. In March 2018, the Veteran underwent a VA examination for non-degenerative arthritis and knee and lower leg conditions. The Veteran reported flare-up sharp pain in both knees that made it hard to walk. He did not report right knee reduced range of motion during the flare-ups. The examiner noted a review of the claims file. Right knee forward flexion was to 120 degrees; extension was to 0 degrees. The examiner noted there was pain but that it did not contribute to functional loss. There was no evidence of pain with weight bearing; no localized tenderness or pain on palpation; and no crepitus. The examiner indicated that the Veteran had neither functional loss nor additional limitation in range of motion in either the knees and or the lower legs post repetitive use testing. Furthermore, the examiner noted that pain, weakness, fatigability or incoordination does not significantly limit functional ability with repeated use over time or during flare ups. Muscle strength testing on a scale was active movement against some resistance (4/5); right knee flexion was 5/5; and right knee extension was 5/5. Also, there was no muscle atrophy or ankylosis. The right knee was normal as to Lachman testing. Likewise, right yielded normal results as to posterior drawer testing. The right knee yielded normal results when valgus/varus pressure was applied to the knees in extension and 30 degrees of flexion. There was no objective evidence of right patellar subluxation. The examiner in accurately noted no indications of meniscal disorder, or meniscal surgery. During a December 2019 hearing, the Veteran indicated since his right knee condition was last rated, he cannot run anymore. The Veteran indicated that the pain was so bad he had to take his National Guard physical readiness test (PT) walking. Although, he was issued a brace he was not allowed to use it during the PT test. See December 2019 Hearing Transcript, p.7. The Board finds no objective evidence that would warrant a compensable rating prior to September 2011 and rating greater than 10 percent for the Veteran's right knee disability, as discussed below. See Estaban, supra. As an initial matter, the Board accepts that the Veteran experienced worsening pain in his right knee, as the Veteran is competent to report unpleasant physical sensation. To this extent, the Board finds him credible. See Layno, supra. However, the Board notes that the Veteran's initial award of a 10 percent disability rating for his right knee was predicated upon his reports of painful motion, not upon loss of flexion or extension. See 38 C.F.R. § 4.59; DeLuca, supra. Thus, 10 percent is the highest award that can be given based solely upon painful motion. Therefore, the Board must determine whether the Veteran has the requisite limitation of flexion or extension that would allow for a grant of a disability rating of 20 percent or higher. It is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes. As such, all relevant diagnostic codes that avoid pyramiding will be discussed below. To receive a compensable rating under Diagnostic Code 5257, there must be slight recurrent subluxation or instability. The evidence of record does not indicate either the presence of slight recurrent subluxation or instability, therefore DC 5257 is not applicable. None of the clinical reports indicated joint instability or positive Lachman's tests. And while the Board notes a history of meniscal damage to the Veteran's right knee, no compensable ratings under Codes 5258 (dislocated semilunar cartilage) or 5259 (removal of semilunar cartilage, symptomatic), are for application for the Veteran's right knee. Also, no separate evaluations of 10 percent for scars because while there are clinical records indicating the Veteran has scars, they are not painful or unstable. Furthermore, there is no evidence suggesting the scars were deep and nonlinear at 6 inches or superficial nonlinear scars measuring at 144 inches. Also, the Veteran did not have a leg flexion of 45 degrees or an extension of the leg at 10 degrees. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran's right knee disability under DC 5260-5024. Furthermore, the Board concludes that these awards are warranted for the entire period under which this appeal has been pending. Accordingly, a rating in excess of 10 percent for painful motion is not warranted because the range of flexion and extension is not 30 degrees or less or 15 degrees or less respectively. However, the Veteran did have surgery to remove cartilage from the knee in 2009 and this was noted as contributing to the pain on motion. Therefore, an additional rating of 10 percent is warranted under Diagnostic Code Diagnostic Code 5259 for symptomatic removal of semilunar cartilage. A higher rating of 20 percent under Diagnostic Code 5258 is not warranted because there is no frequent episodes of locking, pain, and effusion into the joint. The Board has considered the doctrine of reasonable doubt; but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; See Gilbert, supra. REASONS FOR REMAND Cervical Spine (Neck) The Veteran’s service treatment records are silent for any complaints, diagnosis or treatment for a cervical spine (neck) disability. Treatment records while on National Guard active duty for training show that the Veteran sustained injuries when missing the first step and falling down backwards down three quarters of a flight of stairs on July 10, 2011. The Veteran reported falling on his right side on his shoulder and hips. Clinicians diagnosed as a right knee sprain and made note of previous meniscus surgery in 2009. Clinicians noted that X-rays of the shoulder showed no fracture and diagnosed a right shoulder contusion. The Veteran was prescribed anti-inflammatory medication and restricted in running and upper extremity exercise for one week. There was no mention of a head or spinal injury. In December 2019, the Veteran attended a Board hearing. The Veteran reported that while on active duty for training, he fell down a flight of stairs while in full gear, striking the floor or stairs with his head helmet. During that event the Veteran reported that he injured his shoulders and right knee for which he is service connected. Although not noted in his service records, the Veteran indicated the injury to his cervical spine (neck) occurred due to the event that injured his shoulders. See December 2019 Hearing Transcript, p.3-4. The Board cannot make a fully-informed decision on the issue of service connection for a cervical spine disability; because evidence suggest the Veteran’s disability maybe related to his service-connected shoulder disabilities which were caused by the Veteran’s fall while in-service; and there is no VA examiner that has opined as to secondary service connection, and aggravation. As such remand is warranted for a VA examination that discusses direct and secondary service connection. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s right knee disability. The examiner must opine whether: 2. Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's has a current cervical spine (neck) that was caused by his in-service fall? a. Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's cervical spine disability was aggravated (permanently worsened beyond its natural progression) by his service-connected shoulder disabilities? (continued next page) Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, Associate 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.