Citation Nr: 20057167 Decision Date: 08/31/20 Archive Date: 08/31/20 DOCKET NO. 17-12 427 DATE: August 31, 2020 ORDER Entitlement to service connection for a left shoulder disability is dismissed. Entitlement to service connection for dysthymic disorder is granted. Entitlement to service connection for a right elbow disability is granted. Entitlement to service connection for a bilateral foot disability, to include plantar warts, is granted. Entitlement to service connection for a right shoulder disability is granted. Entitlement to service connection for a left elbow disability is denied. Entitlement to an initial rating in excess of 10 percent from October 22, 2013 through January 14, 2020, and in excess of 40 percent from January 15, 2020, for service-connected degenerative arthritis of the lumbar spine is denied. Entitlement to initial ratings in excess of 10 percent for service-connected bilateral knee strains with osteoarthritis is denied. REMANDED Entitlement to service connection for a heart condition, to include an irregular heartbeat is remanded. FINDINGS OF FACT 1. In a June 2020 rating decision, service connection for a left shoulder disability was granted, resulting in a full grant of the benefit sought on appeal. 2. Resolving reasonable doubt in the Veteran’s favor, his dysthymic disorder and right shoulder disability are at least as likely as not related to service. 3. Resolving reasonable doubt in the Veteran’s favor, his right elbow disability and plantar warts of the feet began during active service. 4. The preponderance of the evidence is against finding that a left elbow disability began during active service, or is otherwise related to an in-service injury or disease. 5. From October 22, 2013 through January 14, 2020, the Veteran’s lumbar spine disability did not more nearly approximate 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 not greater than 120 degrees. From January 15, 2020, the Veteran’s lumbar spine disability did not more nearly approximate unfavorable ankylosis of the entire thoracolumbar spine. 6. The Veteran’s bilateral knee strain with osteoarthritis is manifest by pain with flexion. CONCLUSIONS OF LAW 1. The criteria for dismissal of entitlement to service connection for a left shoulder disability have been met. 38 U.S.C. § 7105; 38 C.F.R. § 20.202. 2. The criteria for service connection for dysthymic disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a right elbow disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for plantar warts of the feet have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for a right shoulder disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for a left elbow disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for an initial rating in excess of 10 percent from October 22, 2013 through January 14, 2020, and in excess of 40 percent from January 15, 2020, for degenerative arthritis of the lumbar spine have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5242-5237. 8. The criteria for initial ratings in excess of 10 percent for bilateral knee strains with osteoarthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5003-5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1979 to July 1983, and from September 1984 to August 1992. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The claims were previously remanded by the Board in January 2019. There was substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Additionally, the Board notes that, during the pendency of this appeal, the Veteran submitted letters to the Board in August 2020 asserting entitlement to service connection for bilateral ankle and bilateral hip disabilities, as well as increased rating claims for service-connected hearing loss and tinnitus. As the claims have not been adjudicated by the Agency of Original Jurisdiction (AOJ), they are not properly before the Board. The matters are referred to the AOJ for appropriate action. See 38 C.F.R. § 19.9 (b). Dismissal 1. Entitlement to service connection for a left shoulder disability The claim of entitlement to service connection for a left shoulder disability was initially denied in a March 2015 rating decision. The issue was properly appealed to the Board, and remanded in January 2019 for additional evidentiary development. Subsequently, in June 2020, the RO granted entitlement to service connection for this disability. This is a full grant of benefits sought on appeal, and there is no case or controversy for the Board to adjudicate. Consequently, the claim is dismissed. 38 U.S.C. § 7105. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). VA is responsible for determining whether the evidence supports the claim, with the veteran prevailing, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. 2. Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that he is entitled to service connection for an acquired psychiatric disorder. The Board concludes that the Veteran has a current psychiatric disorder that is related to his military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA mental health treatment notes, and a March 2020 VA examination show the Veteran has a current diagnosis of dysthymic disorder. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes a March 2020 VA medical examination and opinion. During the examination, the Veteran reported two stressors that involved motor vehicle accidents during service. He explained that he rescued fellow soldiers from an accident, and recalled that one of the soldiers was pinned beneath the vehicle. The Veteran also reported that a friend was killed in a motor vehicle accident, and noted that he was supposed to be in the car with his friend when it occurred. The Veteran stated he began drinking during service. The VA examiner opined that the Veteran’s dysthymic disorder was less likely than not incurred in or caused by service. As rationale, the examiner acknowledged that the Veteran experienced traumatic stressors, but the stressors did not meet the criteria for posttraumatic stress disorder. The examiner further stated that the Veteran’s depressed mood, irritability, erratic behavior, and paranoia appeared to be connected to his alcohol use. The evidence in favor of the claim includes VA mental health treatment notes, a private mental health assessment, and lay statements from the Veteran and his spouse. The Veteran submitted a private mental health assessment in November 2015, the Veteran reported that he began drinking while in the military, and discussed the in-service motor vehicle accidents. The private practitioner diagnosed the Veteran with a stressor-related disorder and depressive disorder, and noted that the Veteran’s drinking was more likely than not a form of self-medication. However, he did not provide an etiology opinion regarding the Veteran’s psychiatric disorders. VA mental health treatment notes from July 2018 show the Veteran reported that while stationed in Japan in 1982, a friend died in a motor vehicle accident. The Veteran’s spouse, who was present during the July 2018 appointment, explained that for years the Veteran has experienced nightmares, anxiety, and depression. The Veteran was diagnosed with dysthymia. Additionally, the Veteran’s spouse provided lay statements in December 2015 and November 2019. She stated that the Veteran has suffered from a psychiatric disorder since service. She explains that the Veteran his hypervigilant, forgetful, irritable, withdrawn, and has nightmares that cause him to cry out in the night. The Veteran’s spouse states that while the Veteran has never been violent towards her, she is aware that he was involved in fights while in service, and has said to her nobody will ever treat him the way he was treated in the military. The Veteran also submitted a statement in August 2020, explaining that he has been depressed and mentally distraught for several years, and noted that he faced racial bias while in the military. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current dysthymic disorder is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for dysthymic disorder is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a right elbow disability The Veteran contends that he is entitled to service connection for a right elbow disability. In a January 2020 lay statement, the Veteran reported that he injured his right elbow during a motor vehicle accident that occurred during service. The Board concludes that the Veteran has a current right elbow disability that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA examination reports show the Veteran was diagnosed with degenerative arthritis and bursitis of the right elbow. During service, the Veteran was treated for a right elbow injury following a motor vehicle accident in November 1982. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes February 2015 and January 2020 VA medical examinations and opinions. The Veteran reported injuring his right elbow during an in-service accident. He explained that his current symptoms include aches that worsen during colder weather. The examiners diagnosed degenerative arthritis and bursitis, and each opined that it was less likely than not that the Veteran’s current right elbow condition was related to his military service. As rationale, the examiners acknowledged the Veteran’s history of a right elbow injury during service, but noted that during service the Veteran’s range of motion was normal, it was a soft tissue injury, and he did not have any pain. The evidence in favor of the claim includes a November 2015 medical assessment and opinion from Dr. P.Y, a private physician. Dr. P.Y. stated that the Veteran received blunt force trauma and lacerations to his right elbow during service. At the time of the November 2015 examination, the Veteran was unable to fully extend his right elbow, and was noted to have pain with motion. Dr. P.Y. diagnosed post traumatic residual degenerative joint disease and osteoarthritis, and opined that it is more likely than not that his current right elbow diagnosis is related to his military service. Lastly, Dr. P.Y. stated the Veteran’s condition is permanent and progressive. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current right elbow arthritis is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a right elbow disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for a bilateral foot disability, to include plantar warts The Veteran asserts that he is entitled to service connection for a bilateral foot disability. In lay statements submitted in January 2020 and August 2020, the Veteran reported that he has experienced pain in his feet since service. The Board concludes that the Veteran has a current diagnosis of plantar warts that began during active service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA examinations and private medical assessment show the Veteran has a current diagnosis of plantar warts. During service, the Veteran was seen for complaints of foot corns and callouses, and in October 1980 was noted to have a possible diagnosis of plantar warts. As to whether the current disability is related to service, there are probative opinions in favor of and against the claim. During VA examinations conducted in February 2016 and January 2020, the Veteran was diagnosed with bilateral plantar warts. Both examiners opined that it was less likely than not that the claimed condition of plantar warts were incurred in or caused by service. In support of his opinion, the February 2016 examiner stated that most plantar warts go away without treatment. The examiner noted the probable in-service diagnosis of plantar warts, but stated the Veteran’s service separation foot examination was normal. The January 2020 examiner stated that he was unable to document plantar warts during the examination, nor could he find documentation of plantar warts in the Veteran’s service treatment records. The Board notes that the January 2020 VA medical opinion is inconsistent with the record, as the Veteran’s service treatment records do show he was believed to have plantar warts during service. The evidence in favor of the claim includes a November 2015 private medical assessment from Dr. P.Y., who stated that the Veteran’s plantar warts onset during service and have persisted since. Dr. P.Y. observed the presence of plantar warts during the examination, and stated that because of plantar warts, the Veteran experiences pain and swelling of the feet Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current plantar warts arose in service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for plantar warts of the feet is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for a right shoulder disability The Veteran seeks service connection for a right shoulder disability. In an August 2020 statement, the Veteran indicated he has right shoulder pain due to an in-service motor vehicle accident, and being on basketball and wrestling teams during service. The Board concludes that the Veteran has a current right shoulder disability that is related to service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA medical records and a VA examination show the Veteran has a current diagnosis of arthritis. We must consider the probative opinions of record that are both in favor of and against the claim. The evidence against the claim includes a January 2020 VA examination and medical opinion. The examiner diagnosed a right shoulder rotator cuff tear and osteoarthritis. The Veteran reported that his right shoulder pain began during service and has continued since separation. Upon range of motion testing, he was observed to have reduced motion that causes pain and results in functional loss. The examiner opined that it was less likely than not that the Veteran’s right shoulder disability was not incurred in or caused by service. As rationale, the examiner explained that while the Veteran has reduced range of motion in the right shoulder, his service records do not show that he was treated for a right shoulder condition during service. The Board notes that pain that causes functional impairment, even without an accompanying diagnosis of a present disease, can qualify as a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The evidence in favor of the claim includes the November 2015 opinion from the Veteran’s private physician, Dr. P.Y. He explained that the Veteran has suffered from progressive pain and dysfunction of the right shoulder, and range of motion testing revealed reduced motion. Dr. P.Y. diagnosed post-traumatic residual degenerative joint disease of the right shoulder. He opined that it is more likely that not that the right shoulder disability is related to the Veteran’s in-service motor vehicle accident. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran’s current right shoulder disability arose in service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a right shoulder disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for a left elbow disability The Veteran contends he is entitled to service connection for a left elbow disability. The Board concludes that, while the Veteran has a current diagnosis of bursitis of the left elbow, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of left elbow bursitis began during service or is otherwise related to an in-service injury, event, or disease. Service treatment records are silent for any treatment for or diagnosis of a condition related to the left elbow. Following a review of post-service medical records, there is no indication the Veteran sought treatment for his left elbow. During a February 2015 VA examination, the Veteran did not indicate that he had any issue with his left elbow. During a January 2020 VA examination, though the Veteran was diagnosed with bursitis of the bilateral elbows, the Veteran denied having any concerns related to his left elbow. Both the February 2015 and January 2020 VA examiners opined that the Veteran’s left elbow condition was less likely than not related to service. In a January 2020 lay statement, the Veteran reported that he has pain and severe arthritis in the left elbow. However, he is not competent to provide a nexus opinion regarding this issue as the record does not show that the Veteran has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Further, the January 2020 statement contradicts the Veteran’s previous reports during his VA examinations. Consequently, the Board gives more probative weight to the VA medical opinions. Accordingly, entitlement to service connection for a left elbow disability is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Increased Rating Disability evaluations are determined by applying the criteria set forth in the Schedule for Rating Disabilities to the Veteran’s current symptomatology. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as “staged ratings,” whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505, 519 (2007). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing “for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint.” The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. 7. Entitlement to an initial rating in excess of 10 percent from October 22, 2013 through January 14, 2020, and in excess of 40 percent from January 15, 2020, for service-connected degenerative arthritis of the lumbar spine The Veteran contends that he is entitled to higher ratings for his lumbar spine disability due to the severity of his condition. His degenerative arthritis of the lumbar spine is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5242-5237. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 5242 refers to degenerative arthritis of the spine. Diagnostic Code 5237 refers to lumbosacral strain. 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5237. 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. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. October 22, 2013 – January 14, 2020 The Board finds that from October 22, 2013 through January 14, 2020, the preponderance of the evidence is against a rating in excess of 10 percent for degenerative arthritis of the lumbar spine. The Veteran was afforded a VA examination in October 2014. During range of motion testing, the Veteran demonstrated forward flexion of the lumbar spine to 90 degrees, and had a combined range of motion of 195 degrees. The examiner remarked that during flare-ups, which the Veteran reported occur once or twice each year, the Veteran loses five degrees of motion. During a private assessment from November 2015, the Veteran reported experiencing constant back pain. The Veteran had lumbar spine forward flexion to 30 degrees, and had a combined range of motion to 95 degrees. At a January 2017 VA examination, the Veteran reported a worsening of his low back condition, and that he has difficulty with bending. He also stated that he occasionally visits a chiropractor. During range of motion testing, the Veteran had forward flexion of the lumbar spine to 70 degrees, and a combined range of motion of 220 degrees. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to reduced range of motion, including an estimated additional loss of five degrees during flare-ups that occur no more than twice each year. However, when considering the Veteran’s symptoms and noted functional loss throughout the period prior to January 15, 2020, the degree of additional limitation would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees. We note that during the November 2015 private examination, the Veteran was determined to have forward flexion only to 30 degrees, and a combined range of motion of 95 degrees. The Board finds that when considering the complete disability picture regarding the severity of the Veteran’s lumbar spine from October 22, 2013, through January 14, 2020, the November 2015 examination alone does not provide the most accurate picture of the Veteran’s disability. VA treatment notes dated prior to January 15, 2020, show the Veteran complained of back pain and was treated muscle relaxers. However, there is no indication he required further treatment beyond pain medication and chiropractic care, nor do the treatment notes support a finding for symptoms that warrant a rating in excess of 10 percent. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Both VA examiners noted that the Veteran did not have muscle spasm or guarding, and while the private examiner indicated that there was guarding during muscle testing, there was no indication it resulted in an abnormal gait. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 10 percent for lumbar spine degenerative arthritis from October 22, 2013, through January 14, 2019. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. January 15, 2020 - Present The Board finds that the preponderance of the evidence is against a rating in excess of 40 percent for lumber spine degenerative arthritis since January 15, 2020. The Veteran was afforded a VA examination in January 2020. The Veteran reported having radiating back pain, with flare-ups that occur twice each week lasting two to three hours. He demonstrated lumbar spine forward flexion to 60 degrees, and a combined range of motion of 135 degrees. During flare-ups, the Veteran is estimated to have forward flexion to 30 degrees, and a combined range of motion of 80 degrees. There was no evidence of pain on passive range of motion testing or non-weight bearing testing. Additionally, the examiner noted that the Veteran has guarding or muscle spasm that results in abnormal gait. Even considering the Veteran’s symptoms of pain and reports of flare-ups, the preponderance of the evidence is against a finding that, since January 15, 2020, the Veteran’s lumbar spine disability results in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. The examiner determined that the Veteran did not have ankylosis, nor do medical records show the Veteran has ankylosis of the lumbar spine. Additionally, the Veteran does not have IVDS to warrant a higher rating under a Diagnostic Code 5243. Regarding neurological impairment, the VA examiner also determined that the Veteran has moderate radiculopathy of the right lower extremity. The Veteran is currently service-connected for radiculopathy of the right lower extremity, rated as 20 percent disabling, effective January 15, 2020, the date of the VA examination. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claim for a rating in excess of 40 percent for lumbar spine. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 8. Entitlement to initial ratings in excess of 10 percent for service-connected bilateral knee strains with osteoarthritis The Veteran contends that he is entitled to higher ratings for his bilateral knee strains with osteoarthritis. Each knee was awarded a 10 percent disability rating under Diagnostic Codes 5003-5260, effective October 22, 2013. Diagnostic Code 5003 addresses degenerative arthritis, and Diagnostic Code 5260 addresses limitation of flexion. At the time, the Veteran was noted to have limited flexion, but not to a compensable degree. However, the RO explained in a February 2017 rating decision that the Veteran was awarded the 10 percent evaluations due to painful motion of the knee, pursuant to 38 C.F.R. § 4.59. The Veteran’s knee disabilities are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion of the leg. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for limitation of flexion of the bilateral knees. During the Veteran’s private examination with Dr. P.Y., the Veteran reported experiencing bilateral knee pain that worsens with standing, sitting, and walking. The Veteran demonstrated right knee flexion to 70 degrees, and left knee flexion to 80 degrees. Dr. P.Y. noted the presence of pain with motion. At a January 2017 VA examination, the Veteran reported experiencing worsening bilateral knee pain. He denied having knee flare-ups. Upon range of motion testing, the Veteran demonstrated right knee flexion to 120 degrees, and left knee flexion to 110 degrees, with objective evidence of pain. At the Veteran’s most recent VA examination in January 2020, he reported experiencing bilateral knee flare-ups occurring five to six times each month, lasting up to 24 hours, and are relieved by massage, ice, and pain medication. During range of motion testing, the Veteran demonstrated bilateral knee flexion to 90 degrees, with objective evidence of pain. The Board acknowledges the Veteran’s lay reports of symptoms of pain and flare-ups. However, the preponderance of the evidence is against a finding that his symptoms more nearly approximate flexion limited to 30 degrees. At worst, the Veteran was observed to have right knee flexion to 70 degrees, and left knee flexion to 80 degrees. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). The Veteran is currently in receipt of noncompensable ratings for limitation of extension of the bilateral knees, rated under Diagnostic Codes 5003-5261, effective January 15, 2020. To warrant a compensable rating, the Veteran’s knee extension must be limited to at least 10 degrees. A review of the medical evidence shows that, at worst, the Veteran demonstrated bilateral knee extension to five degrees with pain. The Veteran is not entitled to higher ratings for limitation of extension. Additionally, the Veteran is in receipt of a 10 percent disability rating for impairment of the right knee, effective January 15, 2020, under Diagnostic Code 5257. The rating was awarded based on findings during the January 2020 VA examination showing the Veteran has slight recurrent subluxation and lateral instability of the right knee. A review of the medical evidence fails to show that the severity of the Veteran’s right knee stability warrants a higher rating, or that his left knee was ever noted to have subluxation or instability problems. Regarding the remaining Diagnostic Codes associated with the knees, the Veteran was not found have ankylosis, episodes of locking, meniscus conditions, impairment of the tibia and fibula, or genu recurvatum of either knee. See Diagnostic Codes 5256, 5258, 5259, 5262, and 5263. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim for ratings in excess of 10 percent for bilateral knee osteoarthritis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability, to include an irregular heartbeat, is remanded. The Veteran asserts he is entitled to service connection for a heart disability. In a January 2020 letter, the Veteran stated he has a severe heart defect that has existed since service, and that he has a diagnosis of heart disease. Service treatment records show the Veteran was treated for hypertension while on active duty. In January 2020, a VA examiner opined that it was less likely than not that the Veteran has an irregular heartbeat that incurred in or was caused by service. However, the examiner also remarked that the Veteran needed follow-up care due to a life-threatening finding during the examination. The examiner explained that the findings were pulmonary vascular congestion. Despite acknowledging this diagnosis, the examiner did not consider this condition when issuing a medical opinion. Remand is required to obtain an addendum medical opinion. The matter is REMANDED for the following action: 1. Obtain any outstanding VA medical records and associate them with the claims file. (Continued on the next page)   2. Provide the claims file to an appropriate VA examiner. The entire file must be reviewed by the examiner, and the examiner should provide the following opinion with supporting rationale: (a.) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s pulmonary vascular congestion had its onset in service or is otherwise related to his active service? Cynthia M. Bruce Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Miller, 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.