Citation Nr: 21000199 Decision Date: 01/04/21 Archive Date: 01/04/21 DOCKET NO. 13-20 431 DATE: January 4, 2021 ORDER Entitlement to service connection for left upper extremity peripheral neuropathy is denied. Entitlement to service connection for right upper extremity peripheral neuropathy is denied. Entitlement to service connection for left lower extremity peripheral neuropathy is denied. Entitlement to service connection for right lower extremity peripheral neuropathy is denied. Entitlement to an increased rating in excess of 10 percent for right knee arthritis from April 27, 2011, is denied. Entitlement to a compensable evaluation for right knee limitation of extension from February 6, 2019, is denied. Entitlement to a separate disability rating of 10 percent for instability under Diagnostic Code 5257 for the service-connected right knee disability from February 6, 2019, is granted. FINDINGS OF FACT 1. The preponderance of evidence shows that the Veteran’s left upper extremity peripheral neuropathy was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. The preponderance of evidence shows that the Veteran’s right upper extremity peripheral neuropathy was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 3. The preponderance of evidence shows that the Veteran’s left lower extremity peripheral neuropathy was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 4. The preponderance of evidence shows that the Veteran’s right lower extremity peripheral neuropathy was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 5. The Veteran’s service-connected right knee arthritis disability was manifested by limitation of flexion at worst to 110 degrees, limitation of extension at worst to five degrees, occasional swelling, weakness, and pain on motion; ankylosis and subluxation have not been shown. 6. The Veteran’s service-connected right knee limitation of extension disability was manifested by limitation of extension at worst to 5 degrees. 7. For the period from February 6, 2019, the Veteran’s right knee disability has been manifested by slight instability; moderate instability of the right knee is not more nearly approximated at any time during this period. CONCLUSIONS OF LAW 1. The criteria for service connection for left upper extremity peripheral neuropathy have not been met or approximated. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 2. The criteria for service connection for right upper extremity peripheral neuropathy have not been met or approximated. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 3. The criteria for service connection for left lower extremity peripheral neuropathy have not been met or approximated. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 4. The criteria for service connection for right lower extremity peripheral neuropathy have not been met or approximated. 38 U.S.C. §§ 1110, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020). 5. The criteria for a disability rating in excess of 10 percent for a right knee arthritis disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5260 (2020). 6. The criteria for a compensable rating for a right knee limitation of extension disability have not been met or approximated. 38 U.S.C. §§ 1155, 5107, 7104 (2012); 38 C.F.R. §§ 3.321, 4.1, 4.2, 4.3, 4.7, 4.20, 4.45, 4.59, 4.71a, Diagnostic Code 5261 (2020). 7. The criteria for a separate rating of 10 percent, but not higher, for the service-connected right knee disability on the basis of instability have been met for the period from February 6, 2019. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5257 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1971 to August 1979. This appeal to the Board of Veterans’ Appeals (Board) is from August 2011 and April 2013 decisions of the Department of Veterans Affairs (VA) Regional Office (RO), which denied service connection for a right knee disability and peripheral neuropathy of the bilateral upper and lower extremities, respectively. The Board remanded the issues on appeal for additional development in September 2015, January 2017, and August 2019. The directives having been substantially complied with, the matter again is before the Board. D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). By way of background, in an October 2020 rating decision, service connection for an additional rating for the right knee of limitation of extension was granted with a noncompensable evaluation, effective February 6, 2019. The grant of an increased rating during the course of an appeal does not affect the pendency of that appeal. AB v. Brown, 6 Vet. App. 35 (1993). As the Veteran is presumed to be seeking the maximum allowable benefit and the maximum benefit has not yet been awarded, the claim is still in controversy and on appeal. Id. When a Veteran files a claim for an increased rating, he or she is presumed to be seeking the maximum benefit under any applicable theory, including TDIU. See Rice v. Shinseki, 22 Vet. App. 447, 453–54 (2009). In light of this principle, entitlement to special monthly compensation (SMC) has been found to be an inferable issue anytime a veteran is requesting increased benefits. Akles v. Derwinski, 1 Vet. App. 118 (1991). Here, the Veteran is retired but has not indicated that his service-connected disabilities prevent him from finding and maintaining gainful employment, and as such, the Board declines at this time to infer a claim for TDIU. There is no further lay or medical evidence the Veteran is housebound in fact, requires aid and attendance, or that his disabilities result in loss of use of a limb, blindness or deafness. 38 U.S.C. §§ 1114(s), (l), (k); 38 C.F.R. § 3.350(a), (b), (i). As such, the Board will not infer the issue of entitlement to SMC at this time. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2020). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board….to search the record and address procedural arguments when the [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant’s failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection for Peripheral Neuropathy Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include organic diseases of the nervous system, including peripheral neuropathy, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For peripheral neuropathy, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection for a qualifying peripheral neuropathy disability can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been “shown in service,” there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. Finally, service connection can also be established based on herbicide agent exposure. 38 C.F.R. § 3.307(a)(6). For the purposes of determining herbicide agent exposure, a veteran who served in qualifying locations is presumed to have been exposed to an herbicide agent. 38 C.F.R. § 3.307(a)(6)(iii). The Board has previously conceded the Veteran’s service on the ground in the Republic of Vietnam for the purposes of presumptive herbicide exposure, and will not disturb that finding. If the veteran is presumed to have been exposed to herbicides, the veteran is entitled to a presumption of service connection for certain disorders. See 38 C.F.R. § 3.309(e). This presumption is specifically limited to those diseases listed. Id. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 is presumed to have been exposed to an herbicide agent if a listed chronic disease manifests to a degree of 10 percent disabling or more, unless there is affirmative evidence to the contrary. 38 C.F.R. § 3.307 (a). The presumption is rebuttable. 38 C.F.R. § 3.307(d). Additionally, if a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases are presumed to be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service. See 38 U.S.C. § 1116; 38 C.F.R. § 3.309(e). The diseases associated with herbicide exposure for purposes of the presumption specifically include “early onset peripheral neuropathy.” 38 U.S.C. § 1116 (a)(2); 38 C.F.R. § 3.309(e); see 78 Fed. Reg. 54763 (Sept. 6, 2013). The Board notes there is a distinction between chronic peripheral neuropathy, as previously described above in the discussion about chronic diseases, and the form of peripheral neuropathy possibly associated with herbicide exposure, specifically described as “early-onset peripheral neuropathy.” The time limit for manifestation to a compensable degree is also slightly different: early-onset peripheral neuropathy must become manifest to a compensable degree (10 percent or more) within one year of the last date of in-service exposure to herbicides. See 38 C.F.R. § 3.307(a)(6)(ii) (emphasis added). In that September 6, 2013 change to the regulation, VA also removed Note 2 to § 3.309(e), which had required that the neuropathy be transient and appear within weeks or months of exposure to an herbicide agent and resolve within two years of the date of onset. Under the amendments, peripheral neuropathy still needs to become manifest to a degree of 10 percent or more within one year after the date of last exposure to herbicides in order to qualify for the presumption of service connection, but it no longer needs to be transient. See 78 Fed. Reg. 54763 (Sept. 6, 2013). The Veteran’s last day of service in the country in which he has proven to have been exposed to herbicides should be used as the final date of in-service exposure for calculation purposes. The Board notes from the Veteran’s DD214 in this appeal that his Vietnam service dates were September 14, 1971 to June 5, 1972, and thus will consider the limiting date for the possible manifestation of herbicide-related peripheral neuropathy to be June 5, 1973. As the Veteran’s original date of claim for his peripheral neuropathy is September 4, 2012, prior to the implementation of the September 6, 2013 regulation change, the Board will consider both the original and the newer version of the regulations regarding peripheral neuropathy so as to give the Veteran greater possible benefit in his appeal. Where the evidence does not warrant presumptive service connection, a veteran is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1041 (Fed. Cir. 1994). In other words, a presumption of service connection provided by law is not the sole method for showing causation in establishing a claim for service connection for disability due to herbicide exposure. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Evidence and Analysis The Veteran contends that his peripheral neuropathy in the upper and lower extremities is related to active service, to include as due to exposure to herbicides based his service in Vietnam. The Veteran has also stated that he believes his peripheral neuropathy could be related to his service-connected coronary artery disease, because of the medications used to treat his cardiac conditions. The Board notes medical records indicate the Veteran suffered a myocardial infarction in May 2008, and subsequently underwent an angioplasty to treat the cardiac condition. Cardiac dilatation and hypertrophy have also been noted in the Veteran, and he has been treated with prescriptive medications in addition to periodic examinations and other active treatments. The Veteran has also asserted that his peripheral neuropathy is related to cold weather injuries he suffered while stationed at Fort Riley, Kansas. Because the Veteran’s contention is that all of his peripheral neuropathy symptoms relate to the same cause, regardless of the multiple theories posited, the Board will discuss each extremity’s peripheral neuropathy together as a group for the purposes of discussion and analysis. Service treatment records (STRs) are negative for evidence of peripheral neuropathy through his separation from active duty in August 1979. A July 2008 VA treatment record notes that the Veteran reported myalgia and pain in the upper forearms of unknown etiology. In connection with February 2010 VA treatment, the Veteran indicated he had had intermittent burning in his arms and legs for the past five to six years that gradually worsened. The impression of the neurologist was burning and vibratory sensations in the limbs of unclear etiology that were not due to an inherited or acquired neurodegenerative disorder, but were possibly related to emerging small fiber neuropathy related to alcohol use. According to an October 2010 VA treatment record, the Veteran reported weakness in the lower extremities and was given a neurological examination that was “basically negative” with normal deep tendon patellar reflexes. In connection with January 2011 VA treatment, the Veteran reported numbness and tingling in the upper arms with a notation that he was able to move all four extremities without difficulty. A July 2011 VA treatment note indicates that the Veteran had bilateral numbness and tingling in upper arms secondary to neuropathy, with full strength, full grip, and grossly intact cranial nerves. A February 2012 VA treatment note indicates the Veteran’s radiating pain was likely caused by arthritis. An April 2012 VA treatment note indicates that the Veteran’s worsening neuropathy in both arms was “probably” due to degenerative changes in the cervical spine and that vibrations from driving a truck could increase pain and discomfort. A September 2012 VA treatment note reports bilateral upper extremity numbness and tingling with lower extremity intermittent numbness and tingling that were previously diagnosed as small fiber neuropathy. In connection with April 2013 VA treatment, the Veteran reported a private in-patient hospitalization for sharp, pressured chest pain that radiated into the arms and back. The treatment note indicates that his pain radiated into the shoulders, arms, and his back, worsened with touch, and felt like a bruise. The Veteran was assessed with peripheral neuropathy, questionable flare due to patient’s description and rule out for reflux, irritable bowel, gallbladder, pancreatitis, and pulmonary embolus. A June 2013 VA Agent Orange treatment note reports a history of peripheral sensory neuropathy and indicates that the upper and lower extremities had full strength, with no cyanosis or pedal edema, stable gait, and grossly intact sensory with normal deep tendon reflexes in the upper and lower extremities except for right knee jerk. According to a November 2013 VA treatment note, the Veteran reported chest and back pain that included bilateral tingling in the arms. In a May 2014 VA Agent Orange Peripheral Neuropathy Review Check List, the reviewer found the Veteran’s bilateral upper extremity and bilateral lower extremity peripheral neuropathy did not begin within one year of service. The Veteran received a VA compensation and pension examination for his peripheral neuropathy in June 2018. The examiner here diagnosed bilateral upper extremity and bilateral lower extremity peripheral neuropathy, with a diagnosis date of 2010. The examiner remarked there is no sign of peripheral neuropathy in the service medical records, and the first record is a VA neurology consultation in February 2010 that the Veteran’s paresthesias that he reported began about 5-6 years ago. The examiner also noted there were no signs or symptoms of any developing neuropathy within a year of his military service or following his conceded herbicide exposure. Lower extremity symptoms included a burning sensation in the anterior thighs that was intermittent, with numbness and intermittent vibrations that travel up from the feet. Upper extremity symptoms included numbness and tingling in each hand, with more sensitivity to cold exposure. This June 2018 examiner provided a negative opinion for service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s peripheral neuropathy was a result of the Veteran’s service or any service-connected condition. The examiner’s rationale was there was no sign of any peripheral neuropathy in any service records, or any post-service medical record dating after service ended in August 1979. The examiner pointed out that the Veteran himself mentioned his peripheral neuropathy began about 5-6 years prior to a February 2010 neurology consultation, which would place the approximate onset in 2004. That February 2010 VA neurologist opined at the time that the diagnosis of the peripheral neuropathy was most likely related to the Veteran’s consumption and abuse of alcohol, noting that symptoms declined slightly when the Veteran moderated his alcohol consumption. This examiner also said there was no evidence of any peripheral neuropathy symptoms within a year of his military service. The examiner also considered but rejected the possibility of secondary service connection due to the coronary artery disease, the Veteran’s only service connected condition at the time, by noting that there is no evidence of a causal link between coronary artery disease, including its medications, and any form of peripheral neuropathy. In December 2018, the Veteran was receiving periodic treatment for his service-connected coronary artery disease in a VA facility, and the treating physician noted a “long history” of intermittent burning and pain in the chest extending to bilateral pain in both the arms and the legs. VA provided another examination for the Veteran’s peripheral neuropathy in January 2020, which was uploaded to the claims file in February 2020. The examiner continued previous diagnoses for peripheral neuropathy in all four extremities. The Veteran reported that his peripheral neuropathy started during service when he felt tingling in his hands and feet after pulling guard duty outside in winter conditions while stationed in Kansas. Symptoms of mild and moderate intermittent pain, mild and moderate paresthesias, and mild and moderate numbness were noted. Mild incomplete paralysis for the upper extremities was shown for the radial nerve, median nerve, and ulnar nerve, with the remaining nerves testing normal. For the lower extremities, mild incomplete paralysis was shown for the sciatic nerve, with normal readings for the remaining lower extremity nerves. This January 2020 VA examiner provided multiple opinions for service connection, each to address a particular theory of the Veteran’s contentions. First, this examiner a negative opinion for presumptive service connection via herbicide agent exposure, saying it was less likely than not, less than 50 percent probability, that the Veteran’s peripheral neuropathy was related to any herbicide agent exposure, to include Agent Orange while in Vietnam. The examiner’s rationale was that while the Veteran is considered exposed to herbicide agents due to his service in Vietnam that ended in June 1972, the onset of the Veteran’s diagnosed peripheral neuropathy was not until many years later, approximately 2004 by the examiner’s calculation, which greatly exceeds the one-year limit following the Veteran’s last day of Vietnam service. This examiner next provided a negative opinion for direct service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s diagnosed peripheral neuropathy began during service, due to the cold weather exposures the Veteran endured while stationed at Fort Riley, Kansas. This examiner reviewed the entire medical record and noted the Veteran had no complaints of frostbite or other cold-weather related injury in his service records, and that the type of permanent circulatory damage that might arise from extended cold weather exposure injuries was not the same as peripheral nerve conditions, as diagnosed in this Veteran. The examiner also provided a statement regarding secondary service connection regarding the possible connection to medications taken by the Veteran for his service-connected coronary artery disease, providing a negative opinion for direct service connection, saying it was less likely than not, less than 50 percent probability, that the Veteran’s diagnosed peripheral neuropathy was related to the coronary artery disease, to include the medications taken for it. Again, the reason provided was that the medications taken by the Veteran don’t have any causal relationship with the symptoms associated with peripheral neuropathy. The Board finds the June 2018, January/February 2020, and October 2020 VA examinations and opinions to be of great probative value. The examiners went into detail with the Veteran’s medical and service history, conducted a thorough review of the claims file, and considered the Veteran’s contentions and clinical medical evidence before providing a negative opinion for both direct and presumptive service connection. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). The negative VA opinions considered all of the Veteran’s contentions as to his theories of service connection for his peripheral neuropathy. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The VA examiners’ negative opinions were supported by a sufficiently clear and well-reasoned medical rationale and was consistent with the verifiable facts regarding the Veteran’s contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The Board acknowledges that the Veteran is competent to testify as to his belief that his peripheral neuropathy disabilities are related to service. In order for lay evidence to be competent, the individual must have personal knowledge, derived from his/her own senses, of what is being attested; “[c]ompetent testimony is thus limited to that which the witness has actually observed, and is within the realm of [his] personal knowledge.” Layno v. Brown, 6 Vet. App. 465, 471 (1994). Here, the Veteran is competent to testify about his symptoms relating to his claimed peripheral neuropathy disabilities. However, there is nothing in the record to suggest that the Veteran has the appropriate training, experience, or expertise to render a medical opinion regarding etiology of a peripheral neuropathy disability. See 38 C.F.R. § 3.159 (a)(1) (setting forth that competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions). While the Veteran is competent to report what he has experienced, he is not competent to ascertain the etiology of any current condition, as the causative factors for such are not readily subject to lay observation. See Layno v. Brown, 6 Vet. App. 465 (1994); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, his assertions to that effect are of no probative value. The Board also notes that the Veteran’s service records were silent for any peripheral neuropathy symptoms or related complaint, and his first complaint does not arise until 2004 at the earliest. The Board finds the gap in time between the end of active service in 1979 until the 2004 possible occurrence of symptoms of the peripheral neuropathies to be probative of a lack of nexus between service and the current complaints. There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source. Upon review of the record, the Board concludes that entitlement to service connection for a peripheral neuropathy disability of any of the upper or lower extremities is not warranted. The Board notes a current diagnoses of nephropathy, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran’s contentions, and the Veteran’s post-service statements are noted. The Board notes that the Veteran’s entrance examination, his service treatment records, and his separation examination were all silent for any peripheral neuropathy symptoms, or related injury or incident that led to the nephropathy. The final physical of July 1979, a month prior to separation from active service, is silent for any existing peripheral neuropathy symptoms or related injury at the time of separation from active service, and there is no competent evidence to tie the current assertions to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to presumptive service connection based on herbicide exposure, the Veteran has no diagnosis or condition of early onset peripheral neuropathy that qualifies for presumptive service connection based on herbicide exposure in Vietnam. 38 U.S.C. § 1116(a)(2); 38 C.F.R. § 3.309(e); see 78 Fed. Reg. 54763 (Sept. 6, 2013). Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran’s claimed peripheral neuropathy disabilities were not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a peripheral neuropathy disability of any extremity on a direct or presumptive basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Increased Schedular Ratings - General 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. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § § 4.7. All reasonable doubt as to the degree of disability will be resolved in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § § 4.3. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. The determination of whether an increased disability rating is warranted is to be based on a review of the entire evidence of record and the application of all pertinent regulations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 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 (musculoskeletal system) or § 4.73 (muscle injury); 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 [or 4.73] criteria.”). The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). Additionally, the United States Court of Appeals for Veterans’ Claims (Court) recently addressed what constitutes an adequate explanation for an examiner’s inability to estimate motion loss in terms of degrees during periods of flare-ups. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Sharp, the Court held that a VA examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees could not be given. It also held that any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large, rather than insufficient knowledge by the individual examiner. Id. The Board also notes recent case law where the Court held that 38 C.F.R. § 4.59 does not solely condition the evaluation based on range of motion measurements for a particular diagnostic code, but rather “it conditions that award on evidence of an actually painful, unstable, or maligned joint or periarticular region and the presence of a compensable evaluation in the applicable diagnostic code.” Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Board considers not only the criteria of the currently assigned diagnostic codes, but also the criteria of other potentially applicable diagnostic codes. 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. 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 [or her] earning capacity.” See 38 U.S.C. § 1155 (2012); Brady v. Brown, 4 Vet. App. 203, 206 (1993). This would result in pyramiding, contrary to the provisions of 38 C.F.R. § § 4.14. However, 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). The assignment of a particular diagnostic code is “completely dependent on the facts of a particular case.” See Butts v. Brown, 5 Vet. App. 532, 538 (1993). One diagnostic code may be more appropriate than another based on such factors as an individual’s relevant medical history, the current diagnosis, and the demonstrated symptomatology. Any change in a diagnostic code by VA must be specifically explained. See Pernorio v. Derwinski, 2 Vet. App. 625 (1992). If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Knee Disabilities: Legal Standards In October 2018, the Veteran was granted entitlement to service connection for a right knee condition with arthritis, effective from the original date of claim of April 27, 2011, with an initial evaluation of 10 percent under Diagnostic Code 5260 for leg limitation of flexion. The Veteran then filed a notice of disagreement with that evaluation in November 2018, contending his right knee was worse than the awarded rating indicated. During the appeal period for the right knee arthritis, an additional rating with Diagnostic Codes 5261-5003, leg limitation of extension and arthritis, was granted in an October 2020 rating decision with a noncompensable evaluation effective from February 6, 2019. In assigning hyphenated diagnostic codes, the number assigned to the residual condition on the basis of which the rating is determined will generally represent injuries. Diseases will be identified by the number assigned to the disease itself, with the residual condition added, preceded by a hyphen. 38 C.F.R. § 4.27. VA’s General Counsel has also held that separate ratings may be assigned in cases where a service-connected knee disability includes both a compensable limitation of flexion under DC 5260 and a compensable limitation of extension under DC 5261, provided that the degree of disability is compensable under each set of criteria. VAOPGCPREC 9-2004; 69 Fed. Reg. 59990 (2004). The rationale is that limitation of flexion and limitation of extension are two distinct impediments, i.e., the symptomatology upon which the separate ratings would be based is not duplicative or overlapping. VA General Counsel has also held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability. VAOPGCPREC 23-97 (July 1, 1997). VA’s Office of the General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5060/61 referenced limitation of motion without instability. Id. at para. 2. In other words, the two diagnostic codes addressed different manifestations or symptoms. In Lyles v. Shulkin, 29 Vet. App. 107 (2017), the Court held that evaluation of a knee disability under Diagnostic Codes 5260 and/or 5261 does not, as a matter of law, preclude separate evaluation of a meniscal disability of the same knee under Diagnostic Code 5258 or 5259, and vice versa. The Court further held that entitlement to a separate evaluation in a given case depends on whether the manifestations of disability for which a separate evaluation is being sought have already been compensated by an assigned evaluation under a different Diagnostic Code. In the context of evaluating musculoskeletal disabilities based on limitation of motion, a manifestation of disability has not been compensated, for separate evaluation and pyramiding purposes, if that manifestation did not result in an elevation of the evaluation under 38 C.F.R. §§ 4.40 and 4.45 pursuant to the principles set forth in DeLuca v. Brown, 8 Vet. App. 202 (1995). Included within 38 C.F.R. § 4.71a are multiple Diagnostic Codes that evaluate impairment resulting from service-connected knee disorders, including Diagnostic Code 5256 (ankylosis), Diagnostic Code 5257 (other impairment, including recurrent subluxation or lateral instability), Diagnostic Code 5258 (dislocated semilunar cartilage), Diagnostic Code 5259 (symptomatic removal of semilunar cartilage), Diagnostic Code 5260 (limitation of flexion), Diagnostic Code 5261 (limitation of extension), Diagnostic Code 5262 (impairment of the tibia and fibula), and Diagnostic Code 5263 (genu recurvatum). However, based on the medical evidence before the Board, ankylosis, impairment of the tibia and fibula, and genu recurvatum have not been found or associated with the Veteran’s knee disabilities and thus will not be considered here. Diagnostic Code 5257 provides ratings for recurrent subluxation and/or lateral instability of the knee. A 10 percent rating is assigned for slight recurrent subluxation and/or instability of the knee. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. Under Diagnostic Code 5258, semilunar dislocated cartilage, there is only a single rating of 20 percent specified for frequent episodes of “locking,” pain, and effusion into to the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Under Diagnostic Code 5259, symptomatic removal of semilunar cartilage, there is only a single rating of 10 percent specified: semilunar cartilage, removal of, symptomatic. 38 C.F.R. § 4.71a, Diagnostic Code 5259. Under Diagnostic Code 5260, a non-compensable rating will be assigned for limitation of flexion of the leg to 60 degrees; a 10 percent rating will be assigned for limitation of flexion of the leg to 45 degrees; a 20 percent rating will be assigned for limitation of flexion of the leg to 30 degrees; and a 30 percent rating will be assigned for limitation of flexion of the leg to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a non-compensable rating will be assigned for limitation of extension of the leg to 5 degrees; a 10 percent rating will be assigned for limitation of extension of the leg to 20 degrees; a 20 percent rating will be assigned for limitation of extension of the leg to 15 degrees; a 30 percent rating will be assigned for limitation of extension of the leg to 20 degrees, a 40 percent rating will be assigned for limitation of extension to 30 degrees, and a 50 percent rating will be assigned for limitation of extension to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. Normal range of motion of the knee is to zero degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. For DC 5003, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. 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, rate as follows: a 10 percent evaluation is assigned for painful or limited motion of a major joint or group of minor joints and may also be applied once to multiple joints if there is no limited or painful motion. A 20 percent is assigned for X-ray evidence that shows involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Note (1): The 20 percent and 10 percent ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. 38 C.F.R. § 4.71a. Separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not “duplicative of or overlapping with the symptomatology” of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 262 (1994). See also VAOPGCPREC 9-04 (holding that separate ratings under Diagnostic Code 5260 for limitation of flexion of the knee and Diagnostic Code 5261 for limitation of extension of the knee may be assigned). The terms “slight,” “marked,” “moderate,” and “severe” are not defined in the rating schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to arrive at a just and equitable decision. Additionally, the use of such terminology by VA examiners and others, although an element to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Evidence and Analysis The Veteran’s first VA examination pertinent to the period on appeal from April 27, 2011 for the right knee disability was provided in July 2011. The Veteran reported pain, weakness, and instability in the right knee ever since a 1973 motorcycle accident and that he had had no right knee injury since separation from service. He indicated that he had not sought treatment for his right knee since service. The examiner found the lower extremities properly aligned, grossly symmetric, with full strength, right knee crepitus, normal range of motion, and no fatigue, lack of endurance, incoordination, or pain in the right knee on patellar compression or displacement. The examiner noted that the Veteran reported right anterior knee pain with valgus and posterior valgus stressing and that he felt “loose bodies” inside the joint with repetitive motion. The examiner found the related X-ray report gave an impression of marked focal chondrocalcinosis of the right lateral meniscus with an adjacent articular surface irregularity of the tibial plateau and that, “it is unclear if these findings related to previous trauma,” and diagnosed right knee strains as noted in service treatment records, treated and resolved during military service, with no functional impairment due to pain, pain on repeated use, fatigue, lack of endurance, weakness, or incoordination. Range of motion measurements for the right knee were zero to 140 degrees in flexion and extension. Pain on motion was not noted on this part of the examination. The Veteran received another VA examination for his knees in June 2018. The Veteran noted intermittent swelling of the right knee area and occasional difficulty walking downstairs. The Veteran also said he cannot run or jump and has difficulty kneeling or squatting. Flareups were reported, especially going up and down stairs or inclines. Range of motion measurement were zero to 130 degrees, with 140 being normal, in flexion and extension. There was no evidence of pain with weight bearing, but localized tenderness in the area of the patella tendon and over the superior aspect of the patella was noted. Pain was not noted on passive range of motion or in non-weight-bearing testing. The Veteran could perform three repetitions, but with diminished range of motion as zero to 125 degrees flexion and extension. Muscle strength was five on a scale of five and no ankylosis was noted. No instability or recurrent subluxation was noted, and no evidence of a meniscal condition was noted. Imaging was accomplished and no sign of degenerative or traumatic arthritis was documented on his examination. The final VA examination for the right knee in the period on appeal occurred in February 2019. This examiner diagnosed a chronic right knee sprain with degenerative arthritis. Range of motion measurements were 5 to 110 degrees of extension and flexion, with an ache on the lateral side of the patella during the testing. The examiner noted the severity to be mild and no pain was noted on the examination. There was no objective evidence of crepitus and no evidence of pain on weight bearing. The repetitive use testing resulted in the same range of motion measurements as before. Muscle strength in the right knee was four on a scale of five, but no swelling, deformity, atrophy, instability of station, disturbance of locomotion, or interference with sitting or standing were noted. No ankylosis and no history of lateral instability, recurrent subluxation, or recurrent effusion were noted. However, on this examination, the VA examiner found lateral joint instability in the right knee after applying varus pressure to the knee in extension and with 30 degrees of flexion. For the Veteran’s right knee arthritis under Diagnostic Code 5260, for the entire period on appeal since the original service connection date of April 27, 2011, the Board finds that a 10 percent evaluation, but no higher, is warranted. While the flexion measurements in this period would not warrant a compensable rating for the right knee, a rating of 10 percent is appropriate here due to painful motion of the knee, where the minimum compensable evaluation is 10 percent because 38 C.F.R. § 4.59 allows for consideration of functional loss due to painful motion to be rated to at least the minimum compensable rating for a particular joint. Painful, unstable, or misaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint, which for the right knee, is 10 percent. 38 C.F.R. § 4.59; see Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016); Petitti v. McDonald, 27 Vet. App. 415 (2015). A higher evaluation of 20 percent is not warranted for limitation of flexion unless the evidence shows a limitation of flexion of 16-30 degrees under Diagnostic Code 5260. For the Veteran’s right knee limitation of extension, for the entire period on appeal from the February 6, 2019, the Board finds that a noncompensable evaluation, but no higher, is warranted. At no time during this period did the Veteran’s limitation of extension decrease worst than 5 degrees. A higher evaluation of 10 percent is not warranted unless evidence demonstrates leg extension limited to 10-14 degrees. The Board notes the Veteran’s right knee was rated due to limitation of flexion, limitation of extension, and painful motion due to arthritis under Diagnostic Codes 5260 and 5261-5003. However, this rating does not consider the Veteran’s “give way” weakness and instability, which derives from the same original injury to the right knee. VA examinations record symptoms and statements of instability from the Veteran, and they also note the Veteran’s use of a cane to assist in stable ambulation and to reduce falls. The Board finds that the symptomatology of painful motion used for the original right knee disability rating based on arthritis is distinct from the symptomology for the left knee instability. See 38 C.F.R. § 4.14; Esteban v. Brown, 6 Vet. App. 259, 262 (1994). The Board thus finds that, in addition to the 10 percent rating assigned for the right knee on the basis of limitation of flexion, and the noncompensable rating for extension, an additional 10 percent rating under Diagnostic Code 5257 is appropriate from the date of the examination that found for the right knee instability, from February 6, 2019. A 10 percent rating for instability is the minimum rating described in Diagnostic Code 5257. 38 C.F.R. § 4.71a. See VAOPGCPREC 9-98 (August 14, 1998) (arthritis & instability). VA General Counsel has held that separate ratings may be assigned in cases where the service-connected knee disability includes both arthritis and instability. VAOPGCPREC 23-97 (July 1, 1997). VA’s Office of the General Counsel (OGC) opined that it was not pyramiding to assign ratings under DC 5257 (knee instability) and DC 5260/61 based on additional disability. The opinion explained that DC 5257 addressed instability of the knee without reference to limitation of motion, and DC 5060/61 referenced limitation of motion without instability. Id. at para. 2. In other words, the two diagnostic codes addressed different manifestations or symptoms. The Board has considered the findings regarding objective evidence of knee instability versus subjective reporting of instability by the Veteran in this case. See English v. Wilkie, 30 Vet. App. 347, 353 (2018) (holding that the Board cannot categorically favor objective stability test results over lay reports of instability). Here, the Board notes there were reports of instability by VA medical examiners pertinent to this period from February 6, 2019. Id.; see also Tedesco v. Wilkie, 31 Vet. App. 360, 367 (2019). As to the degree of instability, the Board finds that it has been no more than slight in degree for the period in question. Although the Veteran was prescribed a knee brace and he had some pseudo-laxity medially approximated as 2+, the record does not show that the Veteran consistently falls as a result of a buckling knee or that he would consistently fall but for the use of a brace or a cane. Moreover, the degree of instability indicated during testing in February 2019 supports a finding of slight instability, but not moderate instability, particularly where, as here, some of the VA examiners found no instability. During this period, there was no subluxation noted. Moreover, the Veteran’s statements regarding his instability were that he had difficulty standing due to pain and feelings that he might fall while standing or walking up and down stairs more closely approximate a slight degree of instability during this period, even though VA orthopedic testing for instability, a drawer test, was negative for the right knee in April 2017. Accordingly, the Board finds that the Veteran’s right knee symptoms include occasional instability. In this regard, the evidence does not show, and the Veteran has not argued that any such instability is more than slight in degree, and this is consistent with the VA examiner’s stability testing and observation of stability-related symptoms during examination. Thus, the Board finds that a separate 10 percent rating is warranted for slight instability of the Veteran’s right knee during this period. The Board considers the other symptoms of painful motion of the Veteran’s right knee are adequately covered by already-assigned Diagnostic Codes of 5260 and 5003-5261 for limitation of flexion, limitation of extension, and arthritis used in this period. The Board has considered and found that Diagnostic Codes for limitation of motion, Diagnostic Codes 5260 and 5261, do not provide any additional benefit for the Veteran’s right knee in this period. To warrant the next higher rating above the current 10 percent for painful motion, a 20 percent rating, knee flexion would have to be limited to 30 degrees or less, and/or knee extension would have to be limited to 15 degrees or higher. This has never been shown, even with consideration of additional loss of motion due to pain and swelling during flare-ups. The Board has considered other diagnostic codes for the Veteran’s right knee disability, to include ankylosis (Diagnostic Code 5256), disabilities involving cartilage, semilunar, dislocated, with frequent episodes of locking, pain, and effusion into the joint (Diagnostic Code 5258), removal of the semilunar cartilage (Diagnostic Code 5259), malunion/nonunion of the tibia and fibula (Diagnostic Code 5262), and genu recurvatum (Diagnostic Code 5263), and found them to not apply to the Veteran’s left knee disability picture in this period. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5258, 5259, 5260, 5261, 5262, 5263. The original 10 percent evaluation for the right knee was based on painful motion only, the noncompensable evaluation for the right knee limitation of extension was based on range of motion only, and the Veteran was therefore not adequately compensated for his right knee disability. The additional rating for instability would not compensate the Veteran twice for the same symptoms. Rather, based on the evidence or record, the Board finds that the assignment of an additional rating of 10 percent for instability for the Veteran’s right knee disability for the period from February 6, 2019 is a more accurate assessment of the Veteran’s disability picture for his right knee. A higher rating of 20 percent under Diagnostic Code 5257 is not warranted unless the Veteran’s left knee instability was characterized as “moderate.” No VA or primary medical examiner or treatment provider had ever characterized the Veteran’s right knee instability as moderate, vice slight, in the appeal period. The Board is cognizant that VA examiners have recorded different ranges of motion, but all examiners have noted the consistent pain, pain on motion, and instability of the Veteran’s right knee. Furthermore, the Veteran’s lay statements are consistent over time and correspond to the medical evaluations and treatment notes in the record. “[O]bjective evidence does not necessarily mean [only] medical evidence.” Petitti v. McDonald, 27 Vet. App. 415, 427 (2015); see Southall-Norman v. McDonald, 28 Vet. App. 346, 352 (2016). The Veteran is competent to report pain on motion, instability, and limitation of movement. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Moreover, the Board finds him credible, as his reports are internally consistent and there is no evidence to the contrary. Caluza v. Brown, 7 Vet. App. 498 (1995). Additionally, the Board has considered the statements regarding flareups by the Veteran, but based on the medical evidence, even with estimates of motion loss in terms of degrees during periods of flare-ups, the criteria for higher evaluations based on range of motion have not been met or approximated. Sharp v. Shulkin, 29 Vet. App. 26 (2017). All potentially applicable diagnostic codes have been considered, and there is no basis to assign an alternative evaluation for the Veteran’s right knee disability other than that discussed above. See Schafrath v. Derwinski, 1 Vet. App. 589, 593 (1991). Staged ratings are not warranted beyond that discussed, as the Veteran has had a stable level of symptomatology throughout the appeal period. Any increases in severity were not sufficient for a higher rating for the reasons discussed above. See Hart, 21 Vet. App. 505. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369–70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Setter, 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.