Citation Nr: 21004864 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 09-03 658A DATE: January 28, 2021 ORDER Entitlement to a higher initial rating for residuals of a gastrocnemius tear of the left leg, rated as 10 percent disabling from January 31, 2006, through January 2, 2019, and as 30 percent disabling on and after January 3, 2019, is denied. Prior to November 14, 2017, entitlement to an initial compensable rating for epicondylitis of the left elbow is denied. On and after November 14, 2017, entitlement to an increased rating from 0 percent to 10 percent, but no higher, for epicondylitis of the left elbow is granted. Entitlement to an initial evaluation in excess of 10 percent for excision of a right femoral tumor is denied. Entitlement to service connection for missing and broken teeth is denied. REMANDED Entitlement to an initial evaluation in excess of 20 percent for lumbosacral strain is remanded. Entitlement to a rating in excess of 10 percent for residuals of arthroscopic meniscectomy of the right knee is remanded. Entitlement to a rating in excess of 10 percent for right knee instability is remanded. FINDINGS OF FACT 1. Prior to January 3, 2019, the Veteran’s residuals of a gastrocnemius tear of the left leg were no more than moderately disabling. 2. On and after January 3, 2019, the Veteran’s residuals of a gastrocnemius tear of the left leg have been assigned a 30 percent rating, which is the maximum schedular rating authorized under the applicable criteria. 3. Prior to November 14, 2017, the Veteran’s epicondylitis of the left elbow manifested in full range of motion without painful motion resulting in functional loss. 4. On and after November 14, 2017, the Veteran’s epicondylitis of the left elbow manifested in full range of motion with objective confirmation of painful motion. 5. The Veteran’s excision of a right femoral tumor does not manifest in malunion or nonunion of the femur; nor does it manifest in scarring with underlying tissue damage, superficial scarring of at least 929 square centimeters, painful and/or unstable scarring, or limitation of function due to scarring. 6. Entitlement to service connection for missing and broken teeth for compensation purposes is prohibited as a matter of law. CONCLUSIONS OF LAW 1. The criteria for entitlement to a higher initial rating for residuals of a gastrocnemius tear of the left leg, rated as 10 percent disabling from January 31, 2006, through January 2, 2019, and as 30 percent disabling on and after January 3, 2019, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.951, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.73, Diagnostic Code 5311. 2. Prior to November 14, 2017, the criteria for entitlement to an initial compensable rating for epicondylitis of the left elbow have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.951, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5205-5213. 3. On and after November 14, 2017, the criteria for entitlement to an increased rating from 0 percent to 10 percent, but no higher, for epicondylitis of the left elbow have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.951, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5024, 5205-5213. 4. The criteria for entitlement to an initial evaluation in excess of 10 percent for excision of a right femoral tumor have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5255, 38 C.F.R. § 4.118, Diagnostic Codes 7801-7805 (2002); 38 C.F.R. § 4.118, Diagnostic Codes 7802, 7803, 7804, 7805 (2018). 5. The criteria for entitlement to service connection for missing and broken teeth for compensation purposes have not been met. 38 U.S.C. §§ 1131, 1712, 5107; 38 C.F.R. §§ 3.303, 3.381, 4.150. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1967 to July 1970 and February 2003 to January 2006. He had subsequent periods of active duty for training and inactive duty training. This matter comes before the Board on appeal from April 2007 and April 2014 Regional Office (RO) rating decisions. In April 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. In April 2018, the Board remanded the claim of “Entitlement to service connection for residuals of a jaw fracture with missing and broken teeth.” In a March 2020 rating decision, the RO granted entitlement to service connection for maxilla posterior open bite malunion. Thus, the “residuals of a jaw fracture” component of this claim has been resolved in a grant, and the only issue remaining from this claim involves service connection for “missing and broken teeth.” Increased Rating Disability ratings are determined by comparing a veteran’s symptoms with criteria listed in VA’s Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. “Staged ratings,” or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See, in general, DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of “the normal working movements of the body” such as “excursion, strength, speed, coordination, and endurance,” in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Estimates of additional functional impairment during flare-ups, if any, are also to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 1. Entitlement to a higher initial rating for residuals of a gastrocnemius tear of the left leg, rated as 10 percent disabling from January 31, 2006, through January 2, 2019, and as 30 percent disabling on and after January 3, 2019, is denied. The Veteran’s residuals of a gastrocnemius tear of the left leg (Muscle Group XI) are rated under 38 C.F.R. § 4.73, Diagnostic Code 5311. Under this diagnostic code, slight disability warrants a 0 percent rating, moderate disability warrants a 10 percent rating, moderately severe disability warrants a 20 percent rating, and severe disability warrants a 30 percent rating. Muscle Group XI is responsible for: Propulsion, plantar flexion of foot (1); stabilization of arch (2, 3); flexion of toes (4, 5); Flexion of knee (6). Posterior and lateral crural muscles, and muscles of the calf: (1) Triceps surae (gastrocnemius and soleus); (2) tibialis posterior; (3) peroneus longus; (4) peroneus brevis; (5) flexor hallucis longus; (6) flexor digitorum longus; (7) popliteus; (8) plantaris. Muscle injury disabilities are rated as slight, moderate, moderately severe or severe according to criteria based on the type of injury, the history and complaint, and objective findings. 38 C.F.R. § 4.56(d). A slight muscle disability is one where the injury was a simple wound of muscle without debridement or infection. The service department record would show a superficial wound with brief treatment and return to duty. There would be healing with good functional results. There are no cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c). Objectively, there would be a minimal scar, with no evidence of fascial defect, atrophy, or impaired tonus. There would be no impairment of function, or metallic fragments retained in muscle tissue. A moderate muscle disability is one where the injury was either through and through, or a deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the effect of high velocity missile, residuals of debridement, or prolonged infection. The service department record (or other evidence) would show in service treatment for the wound. There would be a consistent complaint of one or more of the cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objectively, the entrance (and if present, exit) scars would be small or linear, indicating short track of missile through muscle tissue. Some loss of deep fascia or muscle substance, or impairment of muscle tonus and loss of power or lowered threshold of fatigue when compared to the sound side would be present. A moderately severe muscle disability is one where the injury was either through and through, or a deep penetrating wound by a small high velocity missile or large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intramuscular scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), and, if present, an inability to keep up with work requirements. Objectively, the entrance (and if present, exit) scars would indicate the track of missile through one or more muscle groups. There would be indications on palpation of loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with sound side. Tests of strength and endurance compared with sound side demonstrate positive evidence of impairment. A severe muscle disability is one where the injury was either through and through, or a deep penetrating wound due to a high velocity missile, or large or multiple low velocity missiles, or one with a shattering bone fracture or open comminuted fracture with extensive debridement, prolonged infection, or sloughing of soft parts, intramuscular binding and scarring. The service department record (or other evidence) would show hospitalization for a prolonged period for treatment of the wound. There would be a consistent complaint of cardinal signs or symptoms of muscle disability as defined in 38 C.F.R. § 4.56(c), which would be worse than that shown for moderately severe injuries, and, if present, an inability to keep up with work requirements. Objectively, there would be ragged, depressed and adherent scars, indicating wide damage to muscle groups in the missile track. Palpation would show loss of deep fascia or muscle substance, or soft flabby muscles in the wound area. Muscles would swell and harden abnormally in contraction. Tests of strength, endurance, or coordinated movements compared with the corresponding muscles of the uninjured side would indicate severe impairment of function. If they happen to be present, the following would also be signs of severe muscle injury: (A) X-ray evidence of minute multiple scattered foreign bodies indicating intramuscular trauma and explosive effect of missile; (B) Adhesion of scar to one of the long bones, scapula, pelvic bones, sacrum or vertebrae, with epithelial sealing over the bone rather than true skin covering in an area where bone is normally protected by muscle; (C) Diminished muscle excitability to pulsed electrical current in electrodiagnostic tests; (D) Visible or measurable atrophy; (E) Adaptive contraction of an opposing group of muscles; (F) Atrophy of muscle groups not in track of the missile, particularly of the trapezius and serratus in wounds of the shoulder girdle; (G) Induration or atrophy of an entire muscle following simple piercing by a projectile. The cardinal signs or symptoms of muscle disability are loss of power, weakness, lowered threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56(c). A March 2007 VA examination report notes that the Veteran’s lower extremity muscle strength was fair and was equal bilaterally. Deep tendon reflexes were fair and equal bilaterally. Monofilament, vibratory, light touch and sharp-dull distinction were intact bilaterally. Feet were warm to the touch with normal hair distribution. Capillary refill was normal and less than five seconds. Pedal pulses were readily palpable. There was no edema or gross muscle atrophy-wasting of the lower extremities. It was noted that the Veteran has some weakness in his calf and the gastrocsoleus. He gets aches, pains, soreness, and tenderness. A lot of repetitive use bothered and irritated his calf as well. He used a cane to get around. No bracing was needed. He was able to do his job, but prolonged standing did irritate it. There was muscle tenderness over the calf. The Veteran had some weakness to plantar flexion of the ankle because of pain in the left calf. There was no evidence of any muscle hernia. There was no joint involvement. Repetitive use did both him and he had to use a cane to get around. A July 2013 VA examination report notes that the Veteran did not have any known fascial defects or evidence of fascial defects associated with any muscle injuries. The Veteran’s muscle substance and function were affected, as there was some impairment of muscle tonus and some loss of muscle substance. It is unclear, however, whether this description applied to his left leg or his right leg, which was also being examined at this time. The Veteran did not have any of the cardinal signs and/or symptoms attributable to his left leg disability. On muscle strength testing, left ankle plantar flexion, which utilizes Muscle Group XI, was full. The Veteran did not have muscle atrophy. It was noted that the Veteran constantly used a cane as a normal mode of locomotion, but that this use was for his right thigh disability. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms. The Board finds that the Veteran’s residuals of a gastrocnemius tear of the left leg most closely approximate the criteria for a moderate rating, rather than a moderately severe rating. Therefore entitlement to a rating in excess of 10 percent is not warranted prior to January 3, 2019. The above evidence reflects no fascial defects. The July 2013 VA examination report suggests some loss of muscle tonus and muscle substance and that function was also affected. However, these symptoms are contemplated by the 10 percent rating. The weakness and tenderness that were noted by in the March 2007 VA examination report are also contemplated by the 10 percent rating. Furthermore, the July 2013 VA examination report expressly found no cardinal signs or symptoms of disability. There is no indication of loss of deep fascia. Nor does the evidence indicate an inability to keep up with work requirements due to this disability during the appeals period. Therefore, the Board finds that entitlement to a rating in excess of 10 percent is not warranted prior to January 3, 2019. Effective January 3, 2019, the Veteran has been in receipt of the maximum disability rating for residuals of a gastrocnemius tear of the left leg. Specifically, the 30 percent rating is the maximum rating available for injury to Muscle Group XI under Diagnostic Code 5311. The Board notes that the Veteran has not identified any symptoms that are not contemplated by this rating. Thus, an increased rating is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Prior to November 14, 2017, entitlement to an initial compensable rating for epicondylitis of the left elbow is denied. 3. On and after November 14, 2017, entitlement to an initial rating of 10 percent, but no higher, for epicondylitis of the left elbow is granted. The Veteran is currently in receipt of a 0 percent rating for epicondylitis of the left elbow. This rating is assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5024. Diagnostic Code 5024 directs that this disability be rated as limitation of motion as degenerative arthritis. Degenerative arthritis is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis, when substantiated by x-rays, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When, however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, 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 Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Ratings of the elbow based on limitation of motion are assigned under 38 C.F.R. § 4.71a, Diagnostic Codes 5206 (for limitation of flexion), 5207 (for limitation of extension), and 5208 (a combined limitation of flexion and extension). Ratings under these diagnostic codes differ depending on whether the dominant (major) or non-dominant (minor) extremity is being rated. In this case, the Veteran is right-hand dominant, so his left upper extremity is rated as his minor extremity. Diagnostic Code 5206 provides a 0 percent rating for limitation of flexion of the minor extremity to 110 degrees and a 10 percent rating for limitation of flexion of the minor extremity to 100 degrees. Higher ratings are available for limitation of flexion of the minor extremity to 90 degrees or less. Diagnostic Code 5207 provides a 10 percent rating for limitation of extension of the minor extremity to 45 degrees. Higher ratings are available for limitation of extension of the minor extremity to 75 degrees or greater. Diagnostic Code 5208 provides a 20 percent rating for a combination of limitation of flexion to 100 degrees and limitation of extension to 45 degrees of the minor extremity. The Veteran contends that he suffers from a painful left elbow. He reported that it swells if he uses it too much and that he has been referred to an orthopedic surgeon because of this issue. (See Board hearing transcript, page 16.) The Veteran reported at his March 2007 VA examination that he has left elbow pain that comes and goes but was currently not symptomatic. On examination, range of motion was full. There was no elbow pain. There was no change in range of motion on repetitive motion testing. The July 2013 VA examination report notes full range of motion on initial and repetitive use with no objective evidence of painful motion. There was no localized tenderness or pain on palpation of the joints/soft tissue. There was no functional loss and/or functional impairment. The Veteran did not satisfy the criteria for a compensable rating under Diagnostic Codes 5206, 5207, and 5208 based on limitation of motion at the time of these examinations. Furthermore, the examination reports do not contain objective confirmation of painful motion, and no credible lay evidence that pain affected some aspect of the normal working movements of the left leg (see Mitchell v. Shinseki, 25 Vet. App. 32 (2011)), therefore a compensable rating is not warranted under Diagnostic Code 5003 based on the evidence from this portion of the appeals period. The Veteran testified at his November 2017 Board hearing that he has received treatment for his left elbow at the Cleveland Clinic, at his physical therapist in Ohio, and at the VA and his family doctor. At his hearing, he provided records from a private medical center. A record dated November 14, 2017, notes that he has had left elbow pain for year, that it gets intermittent flare-ups. He noted that it started hurting two weeks ago and that this episode is more painful than past flare-ups have been. He asked to be referred to Orthopedic for his tennis elbow. On physical examination, there was “[j]oint swelling present – left elbow along medial epicondyle,” “[j]oint tenderness present … over medial epicondyle,” and “left arm weakness with suppination [sic] secondary to medial epicondylitis.” The Board finds that this record, with its factually ascertainable objective confirmation of painful motion, satisfies the criteria for a 10 percent rating under 38 C.F.R. § 4.59 and Diagnostic Code 5003. The Board also notes that the January 2019 VA examination report notes a finding that, even though range of motion was normal on initial testing and three repetitions, there was pain on range of motion that causes functional loss. Flare-ups manifested in pain but were not estimated to result in range of motion loss. There was no pain on passive range of motion or non-weight bearing testing. With respect to the possibility of an earlier effective date for the 10 percent rating based on the earlier left elbow treatment that was identified by the Veteran at his Board hearing, VA sent the Veteran a letter in November 2018, pursuant to the Board’s April 2018 remand directive, asking that he either submit any outstanding private treatment records or complete an authorization allowing VA to obtain such records. As noted in an April 2020 VA Form 21-0961, the Veteran did not respond to this request within the prescribed period. The Board finds that VA has made the appropriate efforts to attempt to obtain this evidence. In the absence of factually ascertainable evidence of functional impairment dated prior to November 14, 2017, an effective date cannot be assigned for the 10 percent rating prior to that date. The Board finds that a rating in excess of 10 percent is not warranted on or after November 14, 2017, as neither the private treatment record nor the VA examination report reflects limitation of motion that would warrant a rating of 20 percent or greater under Diagnostic Code 5206 or 5207, even taking into account functional impairment caused by factors such as pain, weakness, fatigability, incoordination, or pain on movement of a joint. The Board has considered whether a higher rating is warranted under a different diagnostic code. Disabilities of the elbow and the forearm are rated under Diagnostic Codes 5205 through 5213. In the absence of ankylosis, an increased rating is not warranted under Diagnostic Code 5205. The record reflects that the criteria for a compensable rating under Diagnostic Codes 5209 (other impairment of the elbow), 5210 (nonunion of the radius and ulna with false flail joint), 5211 (impairment of the ulna), 5212 (impairment of the radius), and 5213 (impairment of supination and pronation) were not found at any point during the appeals period. The Board notes, in particular, that the January 2019 VA examination report expressly notes that none of these conditions is present. Therefore, a higher or separate rating for the Veteran’s left elbow disability is not warranted. In short, the Board finds that an initial compensable rating for the Veteran’s left elbow disability is not warranted prior to November 14, 2017, and that an increased rating from 0 percent to 10 percent, but no higher, is warranted on and after November 14, 2017. With respect to the assignment of a compensable rating prior to November 14, 2017, and a rating in excess of 10 percent on and after that date, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is such a rating, an even higher rating must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 4. Entitlement to an initial evaluation in excess of 10 percent for excision of a right femoral tumor is denied. The Veteran’s 10 percent rating is assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5255-5003. 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 rating. 38 C.F.R. § 4.27. In the case at hand, Diagnostic Code 5255 applies to impairment of the femur, and the hyphenated diagnostic code directs that the disability be rated as degenerative arthritis (Diagnostic Code 5003). As described above, when limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic code, 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 Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. The April 2007 rating decision notes that it “consider[ed] whether a higher evaluation can be made based on additional disability resulting from pain on use or during flare-ups. In your case, the evidence shows that repetitive use causes increasing symptomatology.” On this basis, it granted the current 10 percent rating. This rating was assigned pursuant to Diagnostic Code 5003. The Board will consider whether a rating in excess of 10 percent is warranted under Diagnostic Code 5255, which applies to impairment of the femur. Under Diagnostic Code 5255, a rating of 10 percent is warranted for malunion with slight knee or hip disability. A 20 percent disability rating is assigned for malunion of the femur with moderate knee or hip disability. A 30 percent rating is warranted for malunion of the femur with marked knee or hip disability. A 60 percent rating is assigned for fracture of the femur surgical neck with false joint, and for nonunion of the femur with loose motion, weight bearing preserved with aid of brace. Finally, an 80 percent rating is warranted for fracture of femur shaft or anatomical neck with nonunion and loose motion. The Veteran discussed his service-connected right leg and knee disabilities together at his Board hearing. His representative noted that the Veteran has “severe limitation in the movement,” and “limitation to include severe instability he has with the knee and the leg itself.” (See Board hearing transcript, page 15.) He also noted that he receives treatment for his leg at the Cleveland Clinic, as well as with VA and his family doctor. As noted above, however, VA sent the Veteran a letter in November 2018, pursuant to the Board’s April 2018 remand directive, asking that he either submit any outstanding private treatment records or complete an authorization allowing VA to obtain such records. As noted in an April 2020 VA Form 21-0961, the Veteran did not respond to this request within the prescribed period. The Board finds that VA has made the appropriate efforts to attempt to obtain this evidence. The March 2007 VA examination report notes that the Veteran has difficulty with prolonged standing and walking due to his femur problem. On examination, he was using a cane for support. The right leg showed healed scars of the proximal and distal femur. There was a little bit of aching, pain, and tenderness in those areas. There was no systemic bone disease. There was no evidence of malunion or nonunion. There was no evidence of drainage, edema, or redness. Repetitive use caused increased symptomatology. No shortening of the leg was noted. The January 2019 VA examination report notes that x-rays showed an intramedullary rod with two threaded screws involving the distal femur. There was no evidence of joint effusion and no evidence of acute fracture or dislocation. The impression was that there was orthopedic hardware involving the distal right femur and no evidence of acute injury. The right knee examination reflects that there was not “[m]ore movement than normal due to flail joints, fracture nonunions, etc.” The Board finds that a rating in excess of 10 percent is not warranted based on the above examination reports. The March 2007 VA examination report expressly notes that there is no evidence of malunion or nonunion, while the January 2019 report found that there were no “flail joints, fracture nonunions, etc.” Furthermore, the medical treatment records do not reflect the presence of malunion or nonunion of the femur. Thus, the Board finds that the criteria for a rating in excess of 10 percent are not met pursuant to Diagnostic Code 5255. The Board has also considered whether a separate compensable rating may be assigned based on scarring from the surgical procedures that were conducted in connection with this disability. The March 2007 VA examination report notes that “Right leg shows healed scars of the proximal and distal femur from his surgery. There is a little bit of aching, pain, and tenderness in those areas.” The July 2013 VA scars/disfigurement examination report notes that the Veteran has a scar on his right thigh secondary to a surgical resection of a femoral tumor. However, this scar is not painful. The scar was not unstable. There were three scars on the right lower extremity. There was a scar on the superior aspect near the right hip that was 6 centimeters in length. There was a scar on the lateral aspect of the right thigh that was 12.5 centimeters in length. There was a scar on the distal aspect of the right thigh that was 3.5 centimeters in length. The scars were not indicated to be deep. The scars did not result in limitation of function. The February 2020 VA examination report notes that none of the scars was painful. There were three scars on the right lower extremity. The first was on the lateral side of the right thigh and was 15 centimeters by 2 centimeters. The second was on the lateral side of the right knee and was 5 centimeters by 2 centimeters. The third was on the lateral side of the pelvic area and was 13 centimeters by 2 centimeters. These scars were estimated to cover approximately 32 square centimeters. (The Board notes that VA examiners are directed that, “For non-linear scars, measure the length and width at their widest point.”) None of the scars was tender to palpation or unstable. There was no underlying soft tissue damage. There was no limitation of function. The Board notes that skin rating criteria that were in effect at the time of the Veteran’s January 31, 2006, claim apply throughout the appeals period. However, effective August 13, 2018, the Board is to apply either the rating criteria that were in effect at the time of the January 31, 2006, claim or the criteria that came into effect on August 13, 2018, whichever are the most favorable to the Veteran. The Board finds that the criteria for entitlement to a separate rating for scarring is not warranted at any point during this appeals period under the former rating criteria. The Board notes that 38 C.F.R. § 4.118, Diagnostic Code 7804, as in effect from August 30, 2002, to October 23, 2008, provided a compensable rating of 10 percent for a superficial scar that was painful on examination. The Board finds that a separate compensable rating for painful scarring is not warranted. The Board notes that the majority of the evidence of record clearly reflects no painful scarring. The Board has considered whether the March 2007 VA examination report suggests painful scarring in its statement that the “Right leg shows healed scars of the proximal and distal femur from his surgery. There is a little bit of aching, pain, and tenderness in those areas.” The Board notes, however, that this statement does not indicate that the scarring itself is painful. Given that the July 2013 and February 2020 examination reports expressly examine the scars themselves to determine whether they are painful and find that they are not, the Board finds that one or more separate 10 percent ratings is not warranted under Diagnostic Code 7804 based on the March 2007 VA examination report. The Board also notes that separate ratings are not warranted based on any of the remaining criteria in effect from August 30, 2002, to October 23, 3008. Diagnostic Code 7800 applies to disfigurement of the head, face, or neck and thus does not apply in this case. Diagnostic Code 7801 applies to scars, other than of the head, face or neck, that are deep or that cause limited motion. In the case at hand, the Veteran’s scars are not deep, and therefore this diagnostic code does not apply in this case. Under Diagnostic Code 7802 as in effect from August 30, 2002, to October 23, 2008, scars that are superficial, are not productive of limitation of motion, and are not on the head, face, or neck warrant a 10 percent evaluation if they involve an area or areas of 144 square inches (929 sq. cm) or more. The Veteran’s scars in the case at hand do not approach this size, and therefore a separate rating is not warranted. Under Diagnostic Code 7803 as in effect from August 30, 2002, to October 23, 2008, scars that are superficial and unstable warrant a 10 percent rating. In the case at hand, the Veteran’s scars are not unstable, and therefore a separate rating is not warranted. Finally, under Diagnostic Code 7805 as in effect from August 30, 2002, to October 23, 2008, scars may also be rated based on the limitation of function of the affected part. In the case at hand, no limitation of function due specifically to scarring has been identified. Thus, a separate compensable rating is not warranted. The Board will now turn to the rating criteria that came into effect on August 13, 2018. Diagnostic Code 7800 still applies to disfigurement of the head, face, or neck and thus does not apply in this case. Diagnostic Code 7801 applies to scars that are associated with underlying soft tissue damage. In the case at hand, the scars do not result in underlying soft tissue damage, and so a separate rating is not warranted. Under the current Diagnostic Code 7802, scars that are superficial, are not productive of limitation of motion, and are not on the head, face, or neck warrant a 10 percent evaluation if they involve an area or areas of 144 square inches (929 sq. cm) or more. The Veteran’s scars in the case at hand do not approach this size, and therefore a separate rating is not warranted. Diagnostic Code 7803 has been repealed and has not been replaced. Diagnostic Code 7804 applies to scars that are unstable or painful. In the case at hand, none of the Veteran’s scars is unstable or painful. Therefore, a separate rating is not warranted. Finally, under Diagnostic Code 7805, scars may also be rated based on the limitation of function of the affected part. In the case at hand, no limitation of function due specifically to scarring has been identified. Thus, a separate compensable rating is not warranted. In summary, the Board finds that entitlement to a rating in excess of 10 percent for excision of a right femoral tumor is not warranted. Nor is entitlement to a separate compensable rating for associated scarring warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Service Connection 5. Entitlement to service connection for missing and broken teeth is denied. The Veteran contends that compensation benefits are warranted for broken teeth that he suffered in service when he was deployed in Iraq. (See Board hearing transcript, pages 25-26.) Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Dental disorders are treated differently than other medical disorders in the VA benefits system. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150. These conditions include various problems of the maxilla, mandible, or temporomandibular articulation; loss of whole or part of the ramus; loss of the condyloid process or coronoid process; loss of the hard palate; or loss of teeth due to loss of substance of the body of the maxilla or mandible due to trauma or disease such as osteomyelitis rather than as a result of periodontal disease. See 38 C.F.R. § 4.150. Treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are not considered disabling conditions, and may be considered service connected solely for establishing eligibility for VA outpatient dental treatment. See 38 C.F.R. § 3.381(a). The Veteran has claimed entitlement to service connection for disabilities of the jaw and the teeth. He essentially contends that these disabilities resulted from an injury that occurred while he was in service when he was knocked down by a 200 pound ammunitions box. (See Board Hearing Transcript, pages 34-35.) Even though the record of that injury does not indicate the Veteran suffered injuries to his teeth and jaw at that time, the service treatment records do reflect that he was treated for dental fractures that existed prior to service and were aggravated by service. (See March 2005 service treatment record.) Service treatment records also note that the Veteran suffered from malnutrition as a child and, as a result, he has weak teeth. As noted above, service connection has already been granted for the Veteran’s “maxilla posterior open bite malunion.” In addition, the record reflects that the Veteran has received VA outpatient dental treatment. (See March 2007 VA dental and oral surgery examination report; VA dental treatment records dated in November 2006, January 2007, April 2007, and May 2007.) Thus, the only issue before the Board is whether compensation benefits are warranted for missing and broken teeth. As noted above, replaceable teeth can only be considered service-connected for the purpose of establishing eligibility for outpatient dental treatment, and not for compensation purposes. Therefore, the claim for service connection for a dental disability for compensation purposes must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). REASONS FOR REMAND 1. Entitlement to an initial evaluation in excess of 20 percent for lumbosacral strain is remanded. 2. Entitlement to a rating in excess of 10 percent for residuals of arthroscopic meniscectomy of the right knee is remanded. 3. Entitlement to a rating in excess of 10 percent for right knee instability is remanded. These claims were previously remanded by the Board in April 2018 so that the Veteran could undergo an examination that complies with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 creates a requirement that certain range of motion testing be conducted whenever possible in cases of joint disabilities. The final sentence provides that “[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint.” The Court found that, to be adequate, a VA examination of the joints must, wherever possible, include the results of the range of motion testing described in the final sentence of § 4.59. The Veteran underwent the requested VA examinations in January 2019. For both the back and the right knee disabilities, the examiner noted that “There is objective evidence of pain on passive range of motion…. There is objective evidence of pain on non-weight bearing testing.” The Board notes, however, that the examiner did not provide the degree at which the pain began. Therefore, the Board must remand these claims to obtain a VA examination that complies with the requirements of Correia. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Afford the Veteran a VA examination to determine the current severity of his low back and right knee disabilities. The Veteran should be interviewed and all indicated tests and studies should be accomplished. All findings should be reported in detail. The Veteran’s claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. (a) Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion (1) on BOTH active and passive motion AND (2) in weight-bearing and non-weight-bearing, if appropriate. If the examiner is unable to conduct the required testing, he or she should clearly explain why that is so. The examiner must note whether the Veteran demonstrates objective evidence of pain on active and passive motion and, if so, at what degree of motion he demonstrates such objective evidence. (b) The examiner should also express an opinion concerning whether there would be additional functional impairment during flare-ups assessed in terms of the degree of additional range of motion loss. If the Veteran is not currently experiencing a flare-up and reports that he has flare-ups, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran’s functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. (continued on next page) TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.