Citation Nr: 21000516 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 15-33 500 DATE: January 5, 2021 ORDER Entitlement to an initial rating greater than 10 percent for patellofemoral pain syndrome of the right knee is denied. Entitlement to an initial rating greater than 10 percent for lateral collateral ligament of the left ankle is denied. Entitlement to an initial rating greater than 10 percent for left middle finger mallet deformity is denied. Entitlement to SMC at the housebound rate is granted, effective November 4, 2013, subject to the law and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. The Veteran’s patellofemoral pain syndrome of the right knee is manifested by pain and noncompensable limited motion. 2. The Veteran’s lateral collateral ligament of the left ankle is manifested by complaints of pain, swelling, laxity, and limited motion. 3. The Veteran is right-hand dominant. 4. The Veteran’s left middle finger mallet deformity is manifested by limitation of motion and pain. 5. From November 4, 2013, the evidence of record supports the conclusion that the Veteran has a service-connected disability rated as total and additional service-connected disabilities independently ratable at 60 percent or more. CONCLUSIONS OF LAW 1. The criteria for entitlement to an increased rating greater than 10 percent for patellofemoral pain syndrome of the right knee are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5260 (2019). 2. The criteria for entitlement to an increased rating greater than 10 percent for lateral collateral ligament of the left ankle are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5271 (2019). 3. The criteria for entitlement to an increased rating greater than 10 percent for left middle finger mallet deformity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5229 (2019). 4. The criteria for SMC at the housebound rate are met from November 4, 2013. 38 U.S.C. §§ 1114(s), 5101, 5103, 5103A, 5107, 5121 (2012); 38 C.F.R. § 3.350 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty in the U.S. Army from February 1976 to March 1979. As an initial matter, the Board notes that the issue of entitlement to TDIU was remanded by the Board in multiple previous decisions. At the time of the most recent Board determination in March 2020, the Veteran was in receipt of a 100 percent disability rating for his service-connected posttraumatic stress disorder (PTSD) from November 4, 2013. Of relevance, the Court of Appeals for Veterans Claims (Court) in Bradley v. Peake, 22 Vet. App. 280 (2008) held that there could be a situation where a veteran had a schedular total rating for a particular service-connected disability, and could establish a TDIU rating for another service-connected disability or disabilities in order to qualify for special monthly compensation (SMC) under 38 U.S.C. § 1114(s) by having an “additional” disability or disabilities combining to 60 percent or more (“housebound” rate). See 38 U.S.C. § 1114(s); see also Buie v. Shinseki, 24 Vet. App. 242, 250 (2011) (discussing VA’s “well-established” duty to maximize a claimant’s benefits). In this case, again, the Veteran has a 100 percent rating for his service-connected PTSD from November 4, 2013, but is not in receipt of SMC benefits at the “housebound” rate for the period of the 100 percent rating. As the issue of SMC at the “housebound” rate is granted herein, the issue of entitlement to TDIU is moot. As such, further discussion of this issue herein is unnecessary. Increased Rating 1. Entitlement to an initial rating greater than 10 percent for patellofemoral pain syndrome of the right knee 2. Entitlement to an initial rating greater than 10 percent for lateral collateral ligament of the left ankle 3. Entitlement to an initial rating greater than 10 percent for left middle finger mallet deformity Disability evaluations are determined by evaluating the extent to which a veteran’s service-connected disability adversely affects his or her ability to function under the ordinary conditions of daily life, including employment, by comparing his or her symptomatology with the criteria set forth in the Schedule for Rating Disabilities. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate DCs identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran’s entire history is reviewed when making a disability determination. See 38 C.F.R. § 4.1. VA must consider whether the Veteran is entitled to “staged” ratings to compensate when his or her disability may have been more severe than at other times during the course of his or her appeal. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various DCs is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability and incoordination. A January 2014 letter from a former employer indicated that when hired the Veteran had been informed of the work hours, but earlier that month the Veteran had indicated that he would not be working the required hours because he was in school. As the Veteran could not work the minimum required hours his employment was terminated. In September 2014, the Veteran had hypoactive reflexes in the bilateral knees and ankles. A November 2014 VA knee examination is of record. The Veteran reported right knee pain, swelling, and a sensation of giving way. The Veteran had flare-ups that limited standing and walking. These limitations resulted in functional loss. Right knee range of motion testing was from 0 to 115 degrees. There was pain noted that caused functional loss. There was mild tenderness to palpation. Following repetitive use testing the range of motion was from 0 to 100 degrees. The Veteran reported flare-ups 3 times per year that was moderate in severity and lasted for 4 to 5 days. Muscle strength was normal in the right knee without evidence of muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability testing showed no evidence of instability. The Veteran had no current or past meniscal condition. The Veteran occasionally used a cane. There was evidence of crepitus. The Veteran worked at the Baltimore VA hospital and was able to work through the right knee disability and took Motrin for the pain. The Veteran underwent a November 2014 VA hand / finger examination. The Veteran reported left middle finger pain when bumped. The Veteran was right-hand dominant. He denied pain flare-ups. There was a gap between the long finger and the proximal transverse crease of the palm that was less than 1 inch. Extension of the finger was painful and no more than 30 degrees. There was additional limitation with repetitive motion testing, but not enough to alter the net testing results documented above. There was functional loss due to less movement than normal and deformity of the finger. Muscle strength was normal and there was no ankylosis. X-rays showed no fracture or dislocation. The finger disability did not affect the Veteran’s ability to work. A November 2014 VA ankle examination included the Veteran’s report of bilateral ankle pain and swelling in the left ankle. The Veteran reported flare-ups that affected his ability to stand and walk. These limitations also resulted in functional loss. Left ankle range of motion testing showed dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 40 degrees. There was pain on weight-bearing and tenderness to palpation. Following repetitive use, dorsiflexion was further limited to 0 to 5 degrees and plantar flexion from 0 to 35 degrees. Flare-ups occurred 4 to 5 times per year that were moderate in nature and lasted for 1 week. During flare-ups the limitation of motion was estimated to be similar to that observed following repetitive motion. Muscle strength was normal in both ankles and there was no evidence of muscle atrophy or ankylosis. There was evidence of left ankle instability, as there was a positive Talar tilt test demonstrating laxity on the left compared to the right ankle. The Veteran occasionally used a cane for the left ankle. The left ankle limited the Veteran’s ability to work full-time due to pain and swelling in the left ankle. In February 2015, the Veteran was given a brace for his right knee and reported a “tingling” sensation in his fingertips. In April 2015, the Veteran reported pain and swelling in the right knee. In June 2015, the Veteran underwent a VA ankle examination. The Veteran reported left ankle pain, swelling, and giving way. He used a brace and cane for the ankle and took medication for pain. The Veteran reported flare-ups, with increased pain and swelling each time the ankle was re-sprained. Standing and walking were limited due to the left ankle condition. Left ankle range of motion testing showed dorsiflexion from 0 to 10 degrees and plantar flexion from 0 to 40 degrees. There was pain with weight-bearing and tenderness to palpation. There was further loss of motion on repetitive motion testing, specifically dorsiflexion was limited to 5 degrees and plantar flexion was limited to 35 degrees. The examiner also indicated that the Veteran’s range of motion would be similarly limited during periods of flare-ups. Muscle strength testing was normal in the bilateral ankles. There was no muscle atrophy or ankylosis. The Talar tilt test showed greater left ankle laxity compared to the right ankle. The Veteran regularly used a brace and cane. The Veteran indicated that he stopped working in 2013 as an internet manager that required a lot of walking that he could not do because of the left ankle problems. The Veteran underwent a VA examination for the right knee in June 2015. The Veteran reported right knee pain and cracking. There were flare-ups with increased pain with prolonged standing, walking, and kneeling. Right knee range of motion was from 0 to 100 degrees. There was pain noted that caused functional loss due to limited standing, walking, or kneeling. There was pain with weight-bearing and moderate tenderness to palpation. There was evidence of crepitus. On repetitive use testing, range of motion decreased to 0 to 90 degrees. Muscle strength was normal and there was no muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or recurrent effusion. Stability testing was entirely normal. There was no evidence of a current or past meniscal condition. The Veteran regularly used a brace. In July 2017, the Veteran was afforded a VA contract examination for his knees. The Veteran reported that he had been driving for Uber, but could not sit for long periods of time. He also had to “hop to the bathroom every morning.” He also discussed difficulty with running or riding a bike. On examination, right knee range of motion was from 0 to 110 degrees. There was functional loss due to difficulty with prolonged sitting. There was no further loss of function following repetitive motion testing. Muscle strength testing was normal. There was no evidence of muscle atrophy or ankylosis. There was no history of recurrent subluxation, lateral instability, or effusion. Joint stability testing was normal. There was no history or evidence of a meniscus condition. The Veteran occasionally used a knee brace. Employment was impacted due to difficulty with prolonged sitting, running, or cycling. There was objective evidence of pain in the right knee on non-weight bearing, passive range of motion that was the same as his active range of motion, and no evidence of pain on passive range of motion testing. The Veteran was afforded a July 2017 examination for his ankles. The Veteran reported left ankle pain that due to offloading resulted in intermittent dull right ankle pain when walking. The Veteran denied flare-ups of ankle flare-ups. There was functional loss due to the Veteran’s inability to walk for long periods of time. Left ankle dorsiflexion was from 0 to 10 degrees and plantar flexion was from 0 to 40 degrees. There was functional loss due to difficulty with ambulation. There was objective evidence of pain on both dorsiflexion and plantar flexion, as well as tenderness to palpation. There was pain with weight bearing, but no crepitus. Repetitive use testing showed no evidence of further functional loss. Ankle muscle strength was normal and there was no muscle atrophy or ankylosis. There was no suspected instability or dislocation of the ankle joint. The Veteran did not have a history of shin splints, stress fractures, Achilles tendonitis, Achilles tendon rupture, malunion of the calcaneus (or calcis) or talus (astragalus), or had a talectomy. There was an occupational impact due to difficulty with sitting. There was objective pain on weight-bearing and passive range of motion that was the same as active motion. In July 2017, the Veteran underwent a VA contract examination for his left middle finger. There was numbness in the distal part of the left middle finger with occasional sharp pain. There was functional loss due to the Veteran’s inability to catch a ball with the left hand anymore. Range of motion testing for the fingers of the left hand was normal for all fingers. There was no gap between the pad of the thumb and the fingers and no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was no further loss of motion with repetitive motion testing. Muscle strength in each hand was normal, and there was no evidence of muscle atrophy or ankylosis. There was functional impact due to difficulty with heavy lifting. There was no objective evidence of pain on non-weight bearing and passive ranges of motion for the right hand fingers were the same. In January 2019, the Veteran reported shooting pain in the right anterior calf that radiated into the knee. That month the Veteran also reported tingling and numbness from the shoulders to the distal hands and fingers. In April 2019, the Veteran reported some pains in his hands / fingers. In October 2019, the Veteran had trace edema in the bilateral ankles. Patellofemoral Pain Syndrome of the Right Knee The Veteran’s right knee disability is rated as 10 percent disabling under DC 5260. The Veteran claims his current rating does not accurately reflect the true nature and degree of his disability. The general rating schedules for limitation of motion of the knee are 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). The Board concludes that a higher rating for the left knee disability is not warranted under DCs 5260 or 5261. The Veteran’s ranges of motion have been shown to be no worse than limited to full extension and 90 degrees of flexion even accounting for limitation during flare-ups or with repetitive use. The foregoing would not warrant a compensable rating under either DC. In addition, no higher or alternative rating under a different DC can be applied. There are other DCs relating to knee disorders, such as DC 5256 (ankylosis of the knee), DC 5257 (recurrent subluxation or lateral instability), DC 5258 (dislocated semilunar cartilage), DC 5259 (removal of semilunar cartilage, symptomatic), DC 5262 (impairment of the tibia and fibula), and DC 5263 (for genu recurvatum). The Veteran’s right knee disability is not manifested by nonunion or malunion of the tibia and fibula, meniscal problems, or genu recurvatum. Ankylosis is “immobility and consolidation of a joint due to disease, injury, surgical procedure.” Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987)). The Veteran is able to move his right knee, albeit with some limitation of motion, so it is clearly not ankylosed. There is no lay or medical evidence of recurrent subluxation or lateral instability. The Board recognizes that during his November 2014 VA examination the Veteran reported a history of a feeling of his right knee giving way, but it is unclear precisely what he meant by that report including whether he was unable to bear full weight because of position or pain. Numerous tests by medical professionals have shown no evidence of subluxation or lateral instability. As such, the Board does not find the Veteran’s report sufficient to grant a separate or higher rating under DCs 5258 or 5259. The Board notes that the Veteran’s functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in the right knee. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability rating currently assigned. Moreover, testing has repeatedly shown normal muscle strength without atrophy. Thus, despite the Veteran’s reported problems associated with the right knee, he clearly is able to use the knee in close to a normal manner, to include duration of use, and, in fact, does so. See 38 C.F.R. § 4.40 (noting that, “A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like.”). There is otherwise no evidence of significant impairment of motor skills, muscle function, or strength attributable to the Veteran’s right knee disability. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted. As shown above, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, regardless of whether they have been raised by the Veteran. In this case, the Board finds that a higher rating is not warranted for any period on appeal. Furthermore, the Board concludes that based on the foregoing evidence assignment of staged ratings is not for application. Lateral Collateral Ligament of the Left Ankle The Veteran’s left ankle disability is currently rated as 10 percent disabling. The Veteran alleges his disability warrants a higher rating. Under DC 5271 (ankle, limited motion), marked limitation of motion in the ankle warrants a 20 percent disability rating, and moderate limitation of motion in the ankle warrants a 10 percent disability rating. See 38 C.F.R. § 4.71a, DC 5271. For purposes of VA compensation, normal dorsiflexion of the ankle is zero to 20 degrees and normal ankle plantar flexion is zero to 45 degrees. See 38 C.F.R. § 4.71a, Plate II. The Board notes that the words “moderate” and “marked” are not defined in the VA Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are “equitable and just.” See 38 C.F.R. § 4.6. The Board concludes that the Veteran’s symptoms do not reflect a disability picture that is more closely akin to marked limitation of ankle motion at any point on appeal and, as such, a rating greater than 10 percent is not warranted. In reaching that conclusion, the Board recognizes that the Veteran has reported pain and limited motion that worsens during flare-ups. That said, objective testing throughout the appellate time period has shown no more than 25 degrees of combined lost motion in the ankle joints out of a possible 65 degrees of normal motion even accounting for decreased motion with repetitive use or during flare-ups. The Board concludes that such a loss of motion more closely approximates moderate loss of motion of the ankle. Although he did report use of a cane or brace and had difficulty with extended standing or walking, he is able to drive for some distance and has sufficient mobility to leave the home. In August and December 2018, he reported to VA clinicians that he was able to install a new roof on his home and perform kitchen renovations while wearing boots. In light of the foregoing, the Board concludes that the Veteran’s left ankle disability most closely approximate that of pain on motion and that a rating greater than 10 percent under DC 5271 is not warranted at any time on appeal. No other applicable DC would warrant an increased rating in this case. DC 5270 provides for a rating for ankylosis of the ankle and DC 5272 for ankylosis of the subastragalar or talar joint. Here, the Veteran’s ankle has limited motion, but is not “frozen,” and therefore is clearly not ankylosed, as confirmed in the multiple VA examinations of record. The Veteran has had noted laxity of the ankle joint, but there is no indication that this has resulted in further functional loss, as the Veteran’s primary complaints have centered on difficulty with extended standing and walking, rather than instability, falls, or similar problems. In addition, additional compensable evaluations are available under DCs 5273 and 5274 for, respectively, malunion of the os calcis (calcaneus) or astragalus (talus), and astragalectomy. There is no evidence of os calcis or excision or malunion of the talus. Rather, the medical evidence indicates the main manifestation of the Veteran’s left ankle disability is from pain with associated loss of motion and some swelling. As noted above, separate disability ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition was not “duplicative of or overlapping with the symptomatology” of the other condition. Here, the Board does not have a formal diagnosis of arthritis of the ankle, but even assuming such a diagnosis, a separate rating for arthritis under 5003 or 5010 is not appropriate. The Board notes that Note (1) of DC 5003 specifically excludes combining 10 percent or 20 percent disability ratings with ratings based on limitation of motion. In the instant case, the Veteran is already rated under DC 5271 based on limitation of motion. As such, separate evaluations under the DC 5003 or 5010 would constitute pyramiding, since the Veteran’s limitations of motion would be evaluated more than once for the ankle. 38 C.F.R. § 4.71a, DCs 5003, 5010. The Board notes that the Veteran’s functional loss was considered, as the medical evidence shows that the Veteran has consistently complained of pain in the left ankle. 38 C.F.R. §§ 4.40, 4.45; see also DeLuca v. Brown, 8 Vet. App. 202 (1995). However, the limitation of motion documented in the medical records as resulting from pain is already contemplated in the disability rating currently assigned. The Board also finds it extremely significant that multiple records have noted normal muscle strength and the absence of muscle atrophy. Thus, despite the Veteran’s reported problems associated with the ankle, he clearly is able to use the ankle in close to a normal manner, to include duration of use, and, in fact, does so. See 38 C.F.R. § 4.40 (noting that, “A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like.”). There is otherwise no evidence of significant impairment of motor skills, muscle function, or strength attributable to the Veteran’s left ankle disability. Consequently, the Board finds that a higher disability rating based on functional loss is not warranted. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran’s left ankle disability. Furthermore, the Board concludes that the Veteran’s symptomatology has been sufficiently consistent throughout the appellate time period that assignment of staged ratings is not for application. Left Middle Finger Mallet Deformity The Veteran contends that his current 10 percent rating under DC 5229 for left finger mallet deformity does not accurately reflect the severity of his condition. DC 5229 contemplates limitation of motion of the index or long finger. A gap of less than one inch (2.5 cm) between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, and; extension is limited by no more than 30 degrees warrants a noncompensable rating. A gap of one inch (2.5 cm) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed the extent possible, or; extension limited by more than 30 degrees warrants a 10 percent rating. 38 C.F.R. § 4.71a, DC 5229. Thus, the Veteran is in receipt of the maximum rating under DC 5229. A higher rating is not available under DC 5226 based on favorable or unfavorable ankylosis of the long finger (and the Board notes that in any case the middle / long finger is not ankylosed). A 20 percent rating could be warranted under DC 5154 for amputation of the long finger, but the evidence does not indicate that the Veteran would be better served had he undergone amputation of the middle / long finger. The Veteran retains full muscle strength in the hand and some movement in the middle finger. As such, the Board finds no basis for concluding that the Veteran’s current symptomatology more closely approximates amputation of the middle finger. As there is no evidence that the middle finger disability affects the functioning of other fingers or the hand as a whole, the Board finds no basis for assigning a separate or higher rating under any other DC. As shown above, and as required by Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991), the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 10 percent for the Veteran’s left middle finger disability. Furthermore, the Board concludes that the Veteran’s symptomatology has been sufficiently consistent throughout the appellate time period that assignment of staged ratings is not for application. 4. Entitlement to SMC at the housebound rate SMC is payable at the housebound rate where the claimant has a single service-connected disorder rated as totally disabling and one or more distinct service-connected disabilities, which are independently ratable at 60 percent or more and involve different anatomical segments or bodily systems. 38 U.S.C. § 1114(s)(1); 38 C.F.R. § 3.350(i). In this case, the Veteran is in receipt of a 100 percent rating for PTSD from November 4, 2013. In addition, from November 4, 2013, the Veteran’s service-connected disabilities include migraine headaches, rated as 30 percent disabling; chronic lumbar strain, rated as 20 percent disabling; middle finger mallet deformity, rated as 10 percent disabling; patellofemoral pain syndrome, right knee, rated as 10 percent disabling; hypertension, rated as 10 percent disabling; lateral collateral ligament sprain, left ankle, rated as 10 percent disabling; and penis wall tear, rated as noncompensable . The combined rating of these disabilities is 60 percent. Thus, the Veteran has a single disability rated as totally disabling and the other disabilities are separately rated as 60 percent disabling. These ratings are effective from November 4, 2013. 38 C.F.R. §§ 4.25, 4.26. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. J. Houbeck, 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.