Citation Nr: 21004341 Decision Date: 01/26/21 Archive Date: 01/26/21 DOCKET NO. 14-06 196 DATE: January 26, 2021 ORDER From December 1, 2009 to December 12, 2019, entitlement to an evaluation of 10 percent, but no higher, for degenerative disc disease of the lumbar spine is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 20 percent for degenerative disc disease of the lumbar spine from December 12, 2019 onward is denied. Entitlement to a 10 percent, but no higher, evaluation for strain of the bilateral hands is granted for the entire appeal period, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation of 10 percent, but no higher, for patellofemoral syndrome of the right knee from December 1, 2009 to December 12, 2019 is granted, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation of 10 percent, but no higher, for patellofemoral syndrome of the left knee from December 1, 2009 to December 12, 2019 is granted for the entire appeal period, subject to the law and regulations governing the award of monetary benefits. Entitlement to an evaluation in excess of 10 percent for patellofemoral syndrome of the right knee from December 12, 2019 is denied. Entitlement to an evaluation in excess of 10 percent for patellofemoral syndrome of the left knee from December 12, 2019 is denied. REMANDED Entitlement to service connection for radiculopathy of the left lower extremity is remanded. FINDINGS OF FACT 1. From December 1, 2009 to December 12, 2019, the Veteran’s lumbar spine disability manifested by forward flexion to 90 degrees, with degenerative joint disease of the lumbar spine, with painful motion resulting in functional impairment and no evidence of ankylosis, abnormal gait or spinal contour. 2. From December 12, 2019, the Veteran’s lumbar spine disability is manifested by forward flexion to 90 degrees, and after repetition, range of motion flexion was to 52 degrees. His lumbar spine disability was not manifested by flexion of 30 degrees or less or favorable ankylosis of the entire lumbar spine. 3. For the entire appeal period, the Veteran’s bilateral hand strain and osteoarthritis is manifested by painful motion of the bilateral hands resulting in functional impairment. 4. From December 1, 2009, the Veteran’s patellofemoral syndrome of the right knee has been manifested by painful motion resulting in functional impairment; but flexion and extension were not shown to be limited to a compensable degree. 5. From December 1, 2009, the Veteran’s patellofemoral syndrome of the left knee has been manifested by painful motion resulting in functional impairment; but flexion and extension were not shown to be limited to a compensable degree. CONCLUSIONS OF LAW 1. From December 1, 2009 to December 12, 2019, the criteria for a 10 percent rating, but no higher, for the Veteran’s lumbar spine disability have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242. 2. From December 12, 2019, the criteria for a rating in excess of 20 percent for the Veteran’s lumbar spine disability have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.7, 4.40, 4.45, 4.71a, Diagnostic Code 5242. 3. The criteria for a 10 percent rating, but no higher, for strain of the bilateral hands have been met for the entire appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.321, 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5299-5010. 4. From December 1, 2009 to December 12, 2019, the criteria for a 10 percent rating, but no higher, for patellofemoral syndrome of the right knee have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 5. From December 1, 2009 to December 12, 2019, the criteria for a 10 percent rating, but no higher, for patellofemoral syndrome of the left knee have been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 6. From December 12, 2019, the criteria for a rating in excess of 10 percent for right knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5260. 7. From December 12, 2019, the criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5260. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1982 to November 2009. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an April 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran was granted service connection for radiculopathy of the right lower extremity in a May 2020 rating decision. Therefore, this issue has been granted in full and will not be addressed any further herein. The Veteran had a hearing before the undersigned in February 2017. A transcript is of record. In August 2018, the Board remanded the claims for additional development. In a May 2020 rating decision, the RO increased the Veteran’s back rating to 20 percent, effective December 12, 2019, increased his left knee and right knee ratings to 10 percent effective December 12, 2019, and granted service connection for his right lower extremity. Increased Ratings A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 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 their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, 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. 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 (2007). Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). 1. Increased rating for lumbar spine In this case, the Veteran was granted service connection for his lumbar spine disability in an April 2010 rating decision and assigned a noncompensable rating. The rating was assigned with an effective date of December 1, 2009, the day after separation from service, as the Veteran filed his claim within one year from the date of separation. Thereafter, his rating was increased to 20 percent in a May 2020 rating decision, effective December 12, 2019. Under the General Rating Formula (for Diagnostic Codes 5235 to 5243 unless 5243 is evaluated under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes), a 10 percent rating is assigned 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 disability rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, combined range of motion of the cervical spine not greater than 170 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 disability rating is assigned for unfavorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine; a 50 percent disability rating is assigned for unfavorable ankylosis of the entire thoracolumbar spine; and a 100 percent disability rating is assigned for unfavorable ankylosis of entire spine. 38 C.F.R. § 4.71a. Also, any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, should be evaluated separately under an appropriate diagnostic code. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note 1. When rated based on incapacitating episodes, a 10 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 1 week but less than 2 weeks during the past 12 months; a 20 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months; a 40 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months; and a 60 percent disability rating is warranted when there are incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, DC 5243, Note (1). The normal findings for range of motion of the lumbar spine are flexion to 90 degrees, extension to 30 degrees, lateral flexion, right and left, to 30 degrees, and rotation, right and left, to 30 degrees. 38 C.F.R. § 4.71a, Plate V. The Veteran was afforded a VA examination for his lumbar spine in February 2010. The examiner noted that the Veteran has had back pain post his L5/SI laminectomy, beginning from active duty. He noted the pain has gotten progressively worse since its onset and that he takes Aleve once or twice a day with good effectiveness. There was no noted history of urinary incontinence, urinary urgency, retention or frequency, or fecal incontinence, obstipation, erectile dysfunction, numbness or paresthesias. There was no history of fatigue, decreased motion, stiffness, weakness, spasms or pain. There was noted flare ups of the Veteran’s spinal condition, which occurred weekly and lasted hours. The Veteran noted precipitating factors for the flare ups were running, bending, stooping and lifting. There were no noted incapacitating episodes of the spine disease and no limitation to walking. The Veteran was restricted to no sports or running or lifting greater than 50 pounds. Upon inspection, the Veteran had normal posture, normal head position and symmetry in appearance. The gait was normal and he had no abnormal spinal contours and no noted lumbar spine ankylosis. There was no noted muscle spasm, localized tenderness or guarding severe enough to be responsible for an abnormal gait or abnormal spinal contour. Muscle tone was normal and there was no noted muscle atrophy. The Veteran’s reflexes were normal. Upon examination, the Veteran’s range of motion measurements were as follows: flexion was to 90 degrees, extension was to 30 degrees, left lateral and right lateral flexion were to 30 degrees, left lateral and right lateral rotation were to 30 degrees and there was no objective evidence of pain on active motion. There were no additional limitations after three repetitions of range of motion. The examiner noted that no objective evidence of pain on range of motion was noted, passive range of motion was unchanged from active range of motion and on repetitive testing, range of motion values were unchanged from baseline values reported and no pain, fatigue, weakness or incoordination was noted. Imaging studies of the lumbar spine revealed that the Veteran had marked degenerative disc disease with bony spinal stenosis at L5-S1, and the rest of the lumbar spine was unremarkable. Alignment and curvature were normal with near complete disc narrowing with sclerotic changes within endplate and associated small marginal osteophyte consistent with degenerative disc disease. The Veteran was noted as having the usual occupation of avionics specialist and not currently being employed. The Veteran was diagnosed with L5-S1 laminectomy with no significant effects on his usual occupation. He did note effects of his usual daily activities, including chores, shopping, exercise and sports. Thereafter, the Veteran testified at a February 2017 Boarding hearing that his lumbar spine disability had worsened since its onset and since his last examination in February 2010. In December 2019 the Veteran was afforded a VA examination in which his diagnoses of degenerative disc disease of the lumbar spine was confirmed. The Veteran’s diagnosis of right lower extremity radiculopathy was also confirmed. The Veteran did not report flare ups of the lumbar spine disability, but did report having functional loss or functional impairment of the lumbar spine regardless of repetitive use. Specifically, the Veteran noted constant radiculopathy with no flares. He noted he had functional loss or functional impairment of the lumbar spine upon squatting down, sitting for long periods of time, gripping, lifting, sometimes steps on a bad day, squatting down to lift, jogging, driving and sitting for long periods of time. Upon examination the Veteran reported forward flexion to 90 degrees, extension to 30 degrees, right and left lateral flexion to 30 degrees, right and left lateral rotation to 30 degrees. He had no noted pain on examination and no evidence of pain with weight bearing. There was no objective evidence of localized tenderness or pain on palpitation of the joints or soft tissue of the lumbar spine. The Veteran was able to perform repetitive use testing with at least three repetitions with no additional loss of function or range of motion after three repetitions. He was examined immediately after repetitive use over time, and pain, weakness, fatiguability or incoordination significantly limited functional ability with repeated use over a period of time. Specifically, the examiner noted lack of endurance caused this functional loss. After repetitive use the Veteran’s range of motion measurements were as follows: his flexion was to 85 degrees, extension was to 25 degrees, right lateral and left lateral flexion was to 25 degrees, right lateral and left lateral rotation was to 25 degrees. The Veteran did not show guarding or muscle spasm of the lumbar spine. Muscular atrophy was also not shown. Straight leg testing was negative. The Veteran had noted radicular pain in his right lower extremity, specifically showing constant pain and paresthesias and numbness. The Veteran’s nerve roots involved were the L4/L5/S1/S2/S3. Radiculopathy was noted as being mild and there was no ankylosis of the spine. The Veteran was noted to have IVDS of the lumbar spine, but had not had any episodes of acute signs or symptoms due to IVDS that require bed rest prescribed by a physician and treated by a physician in the past 12 months. The Veteran was not noted as needing any assistive device for his lumbar spine disability. The examiner noted that the Veteran’s lumbar spine disability impacted his ability to work, specifically with regard to exertional and postural limitations. The examiner noted that non weight bearing range of motion measurements showed flexion to 52 degrees, extension to 25 degrees, right lateral measurements and left lateral measurements each to 30 degrees. There was no pain in any maneuvers. Applying the facts in this case to the criteria set forth above, the Board finds that from December 1, 2009, the day after separation, to December 12, 2019, a 10 percent rating, but no higher, is warranted for the Veteran’s lumbar spine disability. In this regard, the Veteran has reported at his February 2010 VA examination that he had flare-ups and pain in the lumbar spine, specifically restricting running, bending, stooping and lifting. The Board notes that the intent of the Rating Schedule is to “recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” 38 C.F.R. § 4.59. Given that there is evidence of lumbar spine disability pain which has caused at least some functional impairment, the Board resolves the benefit of the doubt in the Veteran’s favor and finds that the evidence is at least evenly balanced as to whether there is painful motion warranting a 10 percent rating under 38 C.F.R. § 4.59 prior to December 12, 2019. In order to warrant a higher rating than 10 percent prior to December 12, 2019, there must be 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. However, the evidence of record does more nearly approximate these criteria prior to December 12, 2019, to include as due to pain, weakness, premature or excess fatigability and incoordination. The Board finds that a rating in excess of 20 percent from December 12, 2019 is not warranted. In order to warrant a higher rating from December 12, 2019, there must be limitation of flexion to 30 degrees or less or ankylosis of the entire spine. In this case, however, limitation of flexion to 30 degrees or ankylosis has not been shown by any of the evidence of record, to include as due to pain, weakness, premature or excess fatigability and incoordination. The medical evidence clearly indicates that, at its worst, range of motion has only been limited to 52 degrees flexion and there is no evidence of ankylosis. As for a higher rating under Diagnostic Code 5243 for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, the Board notes that prior to December 12, 2019, there is no indication that the Veteran had intervertebral disc syndrome. Moreover, although at the December 2019 examination there is notation of a diagnosis of IVDS, there is no evidence of incapacitating episodes requiring bed rest prescribed by a physician. As such, a disability rating higher than the currently assigned rating for the service-connected lumbar spine under the rating criteria for intervertebral disc syndrome is not warranted. As to whether additional compensation for neurological impairment is warranted at any time during the appeal period, the General Rating Formula requires consideration of neurological findings, to include bladder or bowel impairment, separate from orthopedic manifestations. The Veteran has already been service connected for his right lower extremity radiculopathy and is receipt of a 10 percent rating. Additionally, there have not been any other neurological findings or bladder or bowel impairment during the appeal period. The preponderance of the evidence is against a rating in excess of 10 percent prior to December 12, 2019 and an increased rating in excess of 20 percent for the Veteran’s service-connected lumbar spine disability from December 12, 2019. For these reasons, the claim is granted in part prior to December 12, 2019 and denied thereafter in excess of 20 percent. 2. Increased rating for bilateral hand strain In this case, an initial noncompensable rating for bilateral hands was assigned in an April 2010 decision with an effective date of December 1, 2009, the day after separation from service. The Veteran’s right hand strain is rated under Diagnostic Codes 5299-5010. 38 C.F.R. § 4.71a. During his hearing before the undersigned he endorsed difficulties writing, swelling, loss of dexterity, and problems with grip. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. Diagnostic Code 5299 refers to the musculoskeletal system. See 38 C.F.R. §§ 4.27, 4.71a, Schedule of ratings-musculoskeletal system. Diagnostic Code 5010 pertains to traumatic arthritis substantiated by X-ray findings. See 38 C.F.R. § 4.71a, Diagnostic Code 5010. Diagnostic Code 5010 provides that traumatic arthritis is to be rated as degenerative arthritis. The rating criteria for degenerative arthritis are found under Diagnostic Code 5003. See 38 C.F.R. § 4.71a, Diagnostic Code 5003. Degenerative or traumatic 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. 38 C.F.R. § 4.71a, DCs 5003, 5010. When 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. Id. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. Under DC 5229, limitation of motion of the index or long finger is assigned a 10 percent rating with a gap of one inch (2.5 centimeters) or more between the fingertip and the proximal transverse crease of the palm, with the finger flexed to the extent possible, or; with extension limited by more than 30 degrees. A noncompensable rating is assigned with a gap of less than one inch (2.5 centimeters) 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. 38 C.F.R. § 4.71a, DC 5229. The Veteran does not have ankylosis or amputation of his fingers. Therefore, DCs 5126-5156 and DCs 5216-5227 are not applicable in this case. The Veteran underwent a VA examination for his hands in February 2010. At that examination the Veteran reported that his bilateral osteoarthritis of the hands had gotten progressively worse and that he treated such with Aleve twice a day. The Veteran noted his dominant hand was his right hand and there was no overall decrease in the Veteran’s hand symptoms and no decrease in hand dexterity. The Veteran reported painful joints in all his fingers after repetitive grasping. The examiner further reported a history of flare ups of all fingers including the thumb. Precipitating factors included grasping, alleviating factors included use of Aleve. He had flare ups weekly, usually lasting for hours. Severity of the flare ups was mild. There was no objective evidence of pain upon range of motion measurements, and the Veteran’s range of motion measurements were normal. There was no noted amputation of a digit or part of a digit, no ankylosis of one or more digits, no deformity of one or more digits and no decreased strength for pushing, pulling or twisting and no decreased dexterity for twisting, probing, writing touching or expression. There were also no other significant physical findings; there was no objective evidence of pain on range of motion noted, passive range of motion was unchanged from active range of motion and on repetitive testing range of motion values were unchanged from baseline values reported and no pain, fatigue, weakness or incoordination was noted. The Veteran had noted X-rays of the hands which showed osteoarthritis of fingers in both hands and bilateral subluxation of the metacarpal in both hands. The examiner noted that the Veteran’s usual occupation was avionics specialist and that he was not currently employed but not retired. The examiner diagnosed the Veteran with strain of all joints bilateral second through fifth fingers and mild bilateral first metacarpal subluxation. Thereafter, the Veteran was afforded a VA examination in December 2019 in which his prior diagnosis of bilateral hand strain, claimed as osteoarthritis of the bilateral hands, was confirmed. The examiner noted that both sides were affected. The examiner reported flare ups of the hands, noting that if he used his hands a lot during the day then at night, there would be pain and that is when he would stop working. The Veteran reported functional loss or functional impairment when gripping, and when lifting and if he used his hands at lot during the day then there would be pain at night. The Veteran’s range of motion was abnormal or outside of range. For his right hand, index finger he had extension to 0 degrees, flexion of MCP to 90 degrees, PIP to 100 degrees and DIP to 70 degrees. The longer finger extension was to 0 degrees, flexion MCP was to 0 degrees, PIP 100 degrees and DIP to 70 degrees. The ring finger extension was to 0 degrees, flexion of the MCP was to 70 degrees, PIP to 100 degrees and DIP to 70 degrees. The little finger extension was to 0 degrees, flexion MCP was to 60 degrees, PIP was to 100 degrees and DIP was to 70 degrees, the Veteran’s thumb range of motion measurements showed extension to 0 degrees, MCP to 60 degrees and IP to 60 degrees. For his left hand, the Veteran’s index finger extension was to 0 degrees, flexion MCP was to 90 degrees, PIP was to 100 degrees and DIP was to 70 degrees. His long finger extension was to 0 degrees, flexion of MCP was to 90 degrees, PIP was to 100 degrees and DIP was to 70 degrees. Ring finger extension was to 0 degrees, flexion of MCP was to 70 degrees, PIP was to 100 degrees, DIP was to 70 degrees. Little finger extension was to 0 degrees, MCP was to 60 degrees, PIP was to 100 degrees, DIP was to 70 degrees. Thumb extension was to 0 degrees, flexion MCP was to 50 degrees, IP was to 90 degrees. There was no gap between the pad of the thumb and the fingers, there was no gap between the finger and the proximal traverse crease of the hands on maximal finger flexion and there was no pain noted on examination for either hand. With regard to both hands, the Veteran was able to perform repetitive use testing with at least three repetitions and there was no additional functional los or range of motion after three repetitions. The examiner noted that pain, weakness, fatigability and incoordination significantly limited functional ability with repeated use over a period of time, specifically caused by lack of endurance. The examiner was not able to describe this in terms of range of motion, claiming to expect 10 percent loss of range of motion at the end of the day. The Veteran reported functional impact specifically with regard to handling and fingering. After review of the record, the Board finds that a rating of 10 percent, but no higher, for the Veteran’s bilateral hand disability is warranted. Applying the facts in this case to the criteria set forth above, the Board finds that a 10 percent rating is warranted for the Veteran’s bilateral hand strain. In this regard, the Veteran has indicated at his February 2010 and December 2019 VA examinations that he has flare ups of his joint symptoms, specifically precipitated by grasping and occurring with mild severity. The Board notes that the intent of the Rating Schedule is to “recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint.” 38 C.F.R. § 4.59. Given that there is evidence of a bilateral hand pain which has caused at least some functional impairment, the Board resolves the benefit of the doubt in the Veteran’s favor and finds that the evidence is at least evenly balanced as to whether there is painful motion warranting a 10 percent rating under 38 C.F.R. § 4.59. Although the Board acknowledges the limitation of motion of the Veteran’s right ring finger, such does not commensurate to a compensable evaluation. Therefore, the assigned evaluation under Diagnostic Codes 5299-5010 is more favorable to the Veteran than evaluation under Diagnostic Code 5230. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010, 5230. Likewise, the Veteran’s limitation of motion of the right index and right long fingers is noncompensable under Diagnostic Code 5229 as the evidence does not demonstrate a gap of one inch (2.5 cm.) or more between the fingertip proximal transverse crease of the palm, or extension of the finger(s) limited by more than 30 degrees. See February 2010 and December 2019 VA Examination Objective Range of Motion Findings (noting no additional loss of motion and/or gaps of one inch or more with repetitive use testing). Therefore, the assigned evaluation under Diagnostic Codes 5299-5010 is more favorable to the Veteran than evaluation(s) under Diagnostic Code 5229. See 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Codes 5010, 5229. The Board has considered ratings under Diagnostic Codes 5218, 5222, 5225, 5226, and 5227, however, ankylosis has not been shown during the appeal period. Indeed, the February 2010 and December 2019 VA examiners expressly found that no ankylosis was present. Therefore, the service-connected bilateral hand disabilities do not approximate a disability based on ankylosis of the finger(s) and a higher rating is not warranted under these Diagnostic Codes. In sum, the Board concludes the preponderance of the evidence warrants the assignment of a 10 percent rating, but no higher, for bilateral hand strain. 3. Increased rating for the bilateral knees The Veteran was granted service connection for his bilateral knees in an April 2010 rating decision and granted an initial noncompensable rating, pursuant to 38 C.F.R. § 4.71a, Diagnostic Codes 5010-5260 (traumatic arthritis; limitation of leg flexion). The effective date of the rating decision was December 1, 2009, one day after separation from service. In May 2020 the RO increased his rating for the right knee and the left knee to 10 percent each, effective December 12, 2019. The applicable rating codes are as follows. Pursuant to Diagnostic Code 5260, when flexion of the leg is limited to 60 degrees, a noncompensable rating is warranted. When flexion is limited to 45 degrees, a 10 percent rating is warranted. Flexion limited to 30 degrees warrants a 20 percent rating, while flexion limited to 15 degrees warrants the maximum 30 percent rating. Diagnostic Code 5261 rates based on limitation of leg extension. That code provides that when extension is limited to 5 degrees, a noncompensable rating is assigned. Extension limited to 10 degrees warrants a 10 percent rating. When limitation of extension is at 15 degrees, a 20 percent rating is warranted. Extension limited to 20 degrees warrants a 30 percent rating. Extension limited to 30 degrees warrants a 40 percent rating. Lastly, extension limited to 45 degrees warrants the maximum, 50 percent rating. Under Diagnostic Code 5258, a 20 percent is warranted for cartilage, semilunar, dislocated, with frequent episodes of “locking,” pain, and effusion in to the joint. The Board also notes that under Diagnostic Code 5259, a 10 percent rating is warranted for cartilage, semilunar, removal of, symptomatic. VA General Counsel has held that separate evaluations under Diagnostic Code 5260 (limitation of flexion of the leg) and Diagnostic Code 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. VAOGCPREC 9-2004, 69 Fed. Reg. 59990 (September 17, 2004). The Board notes that the Veteran has shown joint instability at his February 2010 VA examination and that therefore, the Board will consider 38 C.F.R. § 4.71a, Diagnostic Code 5257, for other impairment of the knee, including subluxation or lateral instability. Under that code, slight impairment is assigned a 10 percent rating, moderate impairment a 20 percent rating, and severe impairment a 30 percent rating. The terms “mild,” “moderate,” and “severe” are not defined in the 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.” 38 C.F.R. § 4.6. It should also be noted that use of terminology such as “mild” or “moderate” by VA examiners and others, although an element of evidence 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. In February 2010 the Veteran was afforded a VA examination for his bilateral joint/knee disabilities. At that examination, the Veteran described that pain from his patellofemoral knee syndrome had gotten progressively worse over the years. He reported taking Aleve for the knees twice a day with good effectiveness of treatment. The examiner noted no history of hospitalization or surgery, with no history of trauma to the joints. The Veteran showed no deformity of the bilateral knees but did report giving way, instability, pain and stiffness. The Veteran did not report weakness, but did report incoordination. There was no decreased speed of joint motion and no episodes of dislocation or subluxation. There were no locking episodes and no effusions. Flare ups of the knees were reported, of mild severity occurring weekly and lasting 1-2 days. Precipitating factors of the flare ups were running and the Veteran reported impairment of no running and no sports. The Veteran reported standing limitations of being able to stand less than three hours, but more than one. He had no limitations to walking and he did not note use of assistive devices. Upon examination, the examiner noted normal inspection and palpitation with no crepitation and no mass behind the knee. There was no clicking or snapping, no grinding, no instability noted, no patellar abnormality and no meniscus abnormality. There were no abnormal tendons or bursae and no other knee abnormalities were noted. The Veteran’s range of motion testing was as follows: his left knee flexion was 0 to 140 degrees, left knee extension was normal. There was no objective evidence of pain with active motion on either knee. The right knee flexion was to 140 degrees and the right knee extension was to 0 degrees. There was no objective evidence of pain following repetitive motion and no additional limitations after three repetitions of range of motion. There was no noted joint ankylosis. The Veteran had imaging of the bilateral knees which showed bilateral retropatellar pain. The Veteran’s usual occupation was avionics specialist and the Veteran was not noted as being currently employed, and not retired. The Veteran reported that he is not working because he has not found employment. Upon examination, the Veteran was diagnosed with patellofemoral pain syndrome. The examiner noted that his knee disabilities affected his ability to exercise, and prevented sports. It also affected his recreation mildly. In December 2019 the Veteran was afforded another examination for his bilateral knees. At that examination the examiner confirmed the Veteran’s patellofemoral syndrome of both knees. The Veteran reported flare ups of the bilateral knees when squatting down, sitting for long periods of time, steps on bad days, lifting and jogging. He noted that sitting for long periods of time bothers his back. The Veteran reported having functional loss or functional impairment of the knees specifically when sitting, squatting, doing stairs, lifting, jogging and sitting for long periods. The Veteran’s range of motion of the right knee showed flexion to 140 degrees and extension to 0 degrees. There was no pain noted on his examination and no evidence of pain with weight bearing. There was also no objective evidence of localized tenderness or pain on palpation. The Veteran showed objective evidence of crepitus. The left knee range of motion measurements showed flexion to 120 degrees and extension to 0 degrees. The examiner noted that the range of motion contributed to functional loss, specifically by causing exertional and postural limitations. Pain was noted on exam, causing functional loss. The examiner noted that the Veteran’s flexion exhibited pain. There was no noted evidence of pain with weight bearing. There was objective evidence of crepitus. The Veteran was able to perform repetitive use testing with at least three repetitions. Upon such repetitive use testing, his left knee showed additional limitation of range of motion to 110 degrees of flexion. His right knee showed functional loss, specifically lack of endurance, and limitation of motion to 115 degrees flexion. The examiner noted that the Veteran’s examination of the knees was conducted during a flare up of the left knee but not of the right knee. The examiner noted with regard to the right and left knee that pain, weakness, fatigability or incoordination significantly limited the functional ability with flare ups. Muscle strength testing of both knees was normal and the Veteran did not show any muscular atrophy. There was no noted history of recurrent subluxation or lateral instability of either knee. The examiner did note a history of recurrent effusion, specifically left knee swelling, occasionally. Joint stability testing was not indicated for the right knee but was performed for the left knee. Such testing showed normal stability of the knee. No history of any meniscal condition was noted. The Veteran did not report the use of any assistive devices. Upon weight bearing range of motion testing the Veteran’s flexion of the left knee was to 120 degrees and right knee was to 125 degrees. Active and passive range of motion testing were the same. The Veteran indicated pain upon left knee range of motion testing only. Based on the foregoing, the Board finds that effective December 1, 2009, a rating of 10 percent, but no higher, is warranted for the Veteran’s patellofemoral syndrome of the right and left knees. In this regard, the Veteran reported at his February 2010 VA examination that he had flare-ups and pain in the right and left knees which affected running and also that he experienced giving way, instability, stiffness and incoordination. Given that there is evidence of a pain resulting from the Veteran’s bilateral knee disabilities which has caused at least some functional impairment, the Board resolves the benefit of the doubt in the Veteran’s favor and finds that the evidence is at least evenly balanced as to whether there is painful motion warranting a 10 percent rating under 38 C.F.R. § 4.59 prior to December 12, 2019. Additionally, during the entire period on appeal (prior to and after December 12, 2019), a disability rating in excess of 10 percent is not warranted for the Veteran’s patellofemoral syndrome of the right and left knees. Specifically, flexion was not shown to be limited to 30 degrees or less and extension was not shown to be limited to 15 degrees or less. In fact, limitation of motion has not been shown to be limited to a compensable degree (45 degrees flexion) or (10 degrees extension) or even at a noncompensable degree (60 degrees flexion) or (5 degrees extension). Therefore, a higher rating under diagnostic codes 5260 or 5261 is not warranted. The Veteran is rated as 10 percent disabling from December 12, 2019 due to painful motion. 38 C.F.R. §§ 4.59, 4.71a, Codes 5260-5261. Moreover, with regard to consideration of Diagnostic Codes 5258 and 5259, although the Board acknowledges the Veteran’s finding of small effusion during the December 2019 VA examination, the evidence of record is otherwise absent symptoms specifically pertaining to the meniscus prior to the December 2019 VA examination when the Veteran reported recurrent effusion in the left knee. Notably, there was no report of locking or dislocation documented during the February 2010 or December 2019 VA examinations. As such, the Board finds that an increased rating is not warranted with consideration of Diagnostic Code 5258 and Diagnostic Code 5259 during either period on appeal. In light of the above, the Board finds that the criteria for a rating in excess of 10 percent for a bilateral knee disability based on limitation of motion and meniscal surgery have not been met. The Board further finds that additional separate ratings are not warranted under additional diagnostic codes. The Board notes that there is no evidence of ankylosis of either knee. Thus, Diagnostic Code 5256 does not apply in this case. Also, there is no documentation of any malunion of the tibia or fibula. Therefore, the Board finds that Diagnostic Code 5262 pertaining to impairment of the tibia and fibula is not for application. Lastly, there was no finding of genu recurvatum, so Diagnostic Code 5263 is not for application. With regard to a rating under Diagnostic Code 5257, evidence of instability has not been shown on objective examination at any point during the appeal period. The Board observes that the Veteran has asserted at his February 2010 examination that on occasion his knees give out and he experiences instability. However, the Board affords more probative value to the results of the VA examinations as the various tests designed to ascertain whether instability (Lachman test, posterior drawer test, valgus/varus) was present were normal. Thus, the Board concludes that a rating under Diagnostic Code 5257 is not for application. REASONS FOR REMAND With regard to the issue of entitlement to service connection for left lower extremity radiculopathy, the Board directed in its prior remand that after additional evidence from the ordered development was assembled, the AOJ was to readjudicate the issues on appeal. If any of the benefits sought remained denied by the AOJ, the Veteran was to be provided a supplemental statement of the case (SSOC) before the matters were returned to the Board. There is no indication in the record that the issue of service connection for left lower extremity radiculopathy was readjudicated by the RO, or that the Veteran was provided an SSOC addressing this issue. Accordingly, the issue of entitlement to service connection for radiculopathy of the left lower extremity must be remanded again so that the AOJ may undertake such action. The matter is REMANDED for the following action: (Continued on the next page)   The issue of entitlement to service connection for left lower extremity radiculopathy should be readjudicated. If any determination remains adverse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Nadia Kamal, 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.