Citation Nr: 21005175 Decision Date: 01/29/21 Archive Date: 01/29/21 DOCKET NO. 14-40 353 DATE: January 29, 2021 ORDER Entitlement to service connection for right-knee disorder (previously claimed as Osgood-Schlatter’s disease), to include as aggravated by active service, is denied. Entitlement to an increased disability evaluation in excess of 10 percent and to an effective date earlier than July 5, 2012 for assignment of the 10 percent disability evaluation for service-connected right-wrist disorder, are denied. REMANDED Entitlement to an increased disability evaluation in excess of 10 percent for service-connected left-hand disorder, to include fracture of the third metacarpal, is remanded. FINDINGS OF FACT 1. The objective medical evidence shows that right-knee disorder (previously claimed as Osgood-Schlatter’s disease) is not caused by an event, injury, or illness during active service, nor was it made worse beyond its natural progression by active service. 2. The objective medical evidence shows that at no time during the appeal period did the Veteran exhibit symptoms of ankylosis of the right wrist. 3. The objective medical evidence shows at no time in the period of one year prior to July 5, 2012 did service-connected right-wrist disorder more closely approximate symptoms of ankylosis. CONCLUSIONS OF LAW 1. The criteria for service connection for right-knee disorder (previously claimed as Osgood-Schlatter’s disease), to include as aggravated by active service, have not been met, nor are they presumed to be. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2019). 2. The criteria for an increased disability evaluation in excess of 10 percent for service-connected right-wrist disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.71a, Diagnostic Codes 5003-5215, 5214 (2019). 3. The criteria for an effective date earlier than July 5, 2012 for the assignment of a 10 percent disability evaluation for service-connected right-wrist disorder have not been met. 38 U.S.C. §§ 1155, 5107, 5110 (2012); 38 C.F.R. §§ 3.1, 3.400 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from October 1992 to October 1995 and from May 1997 to June 1999, for part of which, among his other decorations, he was awarded the Air Assault Badge. In June 2018, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These matters were remanded for development in October 2018. They have now been returned to the Board. 1. Entitlement to service connection for right-knee disorder (previously claimed as Osgood-Schlatter’s Disease), to include as aggravated by active service. The service treatment records (STRs) show in the April 1992 enlistment examination for the Veteran’s first period of active service that the examiner found the Veteran’s lower extremities to be normal. The July 1995 separation examination for the Veteran’s first period of active service shows the Veteran reported past or current swollen/painful joints, but he denied “trick” or locked knee. The examiner made note of the bony, prominent protuberance of the right tibial tubercle and further noted the June 1995 x-ray findings, adding there was resulting “intermittent pain associated.” In March 1997, the Veteran underwent a pre-screening examination for his second period of active service, in which he denied past or current painful/trick joints and impaired use of his legs. He further denied having been discharged from military service for physical reasons. The April 1997 enlistment examination shows the Veteran denied past or current trick/locked knee and swollen/painful joints. The examiner noted the Veteran’s October 1995 medical discharge. Based on the foregoing, the Veteran asserts in his December 2020 Appellate Brief that he entered and was accepted into both periods of active service with a presumption of “soundness.” The presumption of soundness presumes a veteran to be in sound condition when entering service unless a defect, infirmity or disorder is “noted at the time of the examination, acceptance, and enrollment” for service or “clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service.” 38 U.S.C. § 1111. When the presumption is unrebutted, it satisfies the second requirement for a service connection claim under VA regulations, that there be evidence of an in-service occurrence or aggravation of a disease or injury. See Gilbert v. Shinseki, 26 Vet. App. 48, 53 (2012). VA can rebut the presumption with clear and unmistakable evidence that (i) an injury or disease manifesting during service pre-existed it and (ii) was not aggravated by it. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The clear and unmistakable evidence standard does not require the absence of conflicting evidence. Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004). Under the first prong (pre-existence), the evidence “must lead, clearly and unmistakably, to the conclusion that the injury or disease existed before the veteran entered the service.” Id. In fact, the presumption is “rebuttable even in the face of an entrance examination affirmatively indicating that the condition in question was tested and found not to exist upon the service member’s entry into service.” Id. Under the second prong, there must be evidence of a permanent increase in severity. Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). VA must “show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition.” Wagner, 370 F.3d at 1096 (quotes omitted). In so doing, it “must rely on affirmative evidence to prove that there was no aggravation.” Horn v. Shinseki, 25 Vet. App. 231, 235 (2012). An increase in disability refers to an overall worsening of the disability rather than any observable increase in disability, irrespective of temporal duration. Davis v. Principi, 276 F.3d 1341, 1344 (Fed. Cir. 2002). Temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). As both enlistment examinations for the Veteran’s two periods of active service made no specific finding of a right-knee disorder, as well as this being so in the July 1995 separation examination at the end of the first period, the Board finds the Veteran is entitled to the presumption of soundness as to a right-knee disorder. The next question is whether there is clear and unmistakable evidence that a right-knee disorder pre-existed active service. The STRs further show that, in June 1995, the Veteran complained of a lump on his right knee for one week. The examiner noted the “palpable enlargement” of the right tibial tubercle, he found tenderness to palpation over the inferior patellar tendon and assessed the Veteran with inferior patellar tendonitis. June 1995 x-rays revealed a prominent bony protuberance of the right knee with some swelling. However, the overall radiographic appearance suggested to the radiologist indications which “represents some type of old change.” In the Veteran’s second period of active service, the Veteran presented in March 1998 with right-knee pain, reporting he had fallen. The examiner noted the prominent tibial tubercle. He assessed the Veteran with “[p]atella tendonitis/bursitis vs. Osgood Schlatter, ? medial meniscal defect.” The Veteran was referred to physical therapy the same day. The therapist noted the Veteran’s report of right-knee pain for the previous 5 months since falling. He further noted the Veteran has a prominent lump on the tibial tuberosity, “which could be Osgood Schlatter’s, but old medical records [are] not available for review.” He provisionally diagnosed the Veteran with patella tendinitis/bursitis. A therapy consultation report states an assessment to “ R/O [rule out] contusion with possible old Osgood Schlatter.” Right-knee x-rays that day revealed no evidence of fracture, dislocation, joint effusion, arthritic change, or other abnormality. Although the tibial tubercle was prominent, the radiologist concluded that this was a congenital malformation “and most likely of no clinical significance.” An in-service physical therapy note in June 1998 notes right-knee pain for 8 months since falling on a rock. The treatment provider found a prominent right-tibial tubercle. He assessed the Veteran with “[o]ld Osgood Schlatter [with] chronic patellar tendon insert pain[,] not responding to profile.” An August 1998 physical therapy note states an assessment of “[s]ymptomatic, Osgood Schlatter’s[,] not responding to treatment,” with a note to make an orthopedic referral and to continue the physical profile. Several days later in August 1998, an in-service orthopedic clinic note states the Veteran has a nine-month history of right-knee pain, the treatment provider found a prominent tibial tubercle and he assessed the Veteran with patello-femoral right-knee pain and right-knee Osgood Schlatter’s Disease. As indicated above, with the exception of the August 1998 assessment, there is an overall tentativeness in the conclusions of the in-service treatment providers. For example, “patella tendonitis/bursitis vs. Osgood Schlatter, ? medial meniscal defect” seems to say it is either tendonitis or Osgood-Schlatter’s disease and yet it might be the third possibility of meniscal defect. The characterization of “old change” and “old Osgood-Schlatter’s disease” is undercut by the March 1998 treatment provider observing that the Veteran’s older medical records (pre-service) are not available, thereby confirming uncertainty. “Clear and unmistakable evidence” is a more formidable evidentiary burden than the preponderance of the evidence standard. See Vanerson v. West, 12 Vet. App. 254, 258 (1999) (noting that the “clear and convincing” burden of proof, while a higher standard than a preponderance of the evidence, is a lower burden to satisfy than that of “clear and unmistakable evidence”). The burden of proof is on VA to rebut the presumption by producing clear and unmistakable evidence that a disability existed prior to service. See Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). The determination of whether there is clear and unmistakable evidence that a defect, infirmity or disorder existed prior to service should be based on “thorough analysis of the evidentiary showing and careful correlation of all material facts, with due regard to accepted medical principles pertaining to the history, manifestations, clinical course, and character of the particular injury or disease or residuals thereof.” 38 C.F.R. § 3.304 (b)(1) (2007). The physical examination for the Medical Evaluation Board report, the findings and opinion of which were the basis for the Veteran’s medical discharge, took place in January 1999. The Veteran denied past or current “trick” or locked knee and painful or swollen joints, but admitted past or current “bone, joint or other deformity.” The February 1999 report states the chief complaint of right-anterior knee pain. It gives a summary of the above in-service treatment of the Veteran’s right-knee disorder, noting the Veteran’s “prolonged course of physical therapy without significant relief,” as well as summarizing the history of his right-wrist disorder. Its final diagnosis is anterior right-knee pain, “medically unacceptable with AR40-501 chapter 3-41e (1), EPTS [existed prior to service] condition, not aggravated by service.” The Board finds this final diagnosis/opinion problematic. Based on the in-service record of treatment, the examiner concludes that the right-knee disorder existed prior to service and further states it was not aggravated by service. In short, the very deficiencies the Board has identified regarding uncertainty appear to have been adopted by the Medical Evaluation Board. Moreover, no affirmative evidence was adduced to show that the disorder in fact was not aggravated, as required. Horn v. Shinseki, 25 Vet. App. at 235. Given the inconclusive identification in the STRs of Osgood-Schlatter’s disease as a congenital, therefore pre-existing, disorder and the fact that the Medical Evaluation Board findings simply reflect those records and it did not explain why it concluded there had been no aggravation or offer evidence of the absence of aggravation, the Board finds neither the record of in-service treatment nor the Medical Evaluation Board opinion are clear and unmistakable evidence sufficient to rebut the presumption of soundness. In September 2019, the Veteran underwent a VA examination for knee and lower leg conditions, in which the Veteran claimed a condition of right-knee instability, but the VA examiner’s primary diagnosis was only left-knee strain. As a second diagnosis, she stated a June 1995 diagnosis of “Congenital malformation of right tibial tubercle (Osgood-Schlatter’s disease).” She diagnosed a third disorder of enthesopathy (abnormality involving an attachment of a tendon or ligament to bone). The Veteran reported constant, “excruciating” right-knee pain, with only 15-20 minutes of activity, aggravated with prolong sitting, standing, walking at an incline/decline, taking stairs, and squatting. The VA examiner noted the Veteran’s report of injuring his right knee during an in-service training mission in 1995, when he hit his knee on a rock. However, the VA examiner added, “The Veteran was informed the right knee pain is related to a congenital malformation.” On examination, the VA examiner found flexion and extension caused sharp right-knee pain, noting it began at the center of the right knee and traveled up to the right hip and groin. She added that this was related to “[t]ibial tubercle prominence, which is diagnosed as a congenital malformation in the right knee.” Although the Veteran claimed right-knee instability, the VA examiner found no right-knee subluxation or instability during joint stability testing. She noted that available imaging studies had not documented degenerative or traumatic arthritis. She further noted the following other significant diagnostic test findings or results: A June 1995 right-knee x-ray reveals a prominent, bony protuberance at the tibial tubercle, with some adjacent soft tissue swelling. A March 1998 x-ray reveals tibial tubercle prominent in its upper-portion-congenital malformation. January 1999 x-ray imaging impression interprets Osgood-Schlatter’s disease. A September 2019 x-ray (from that day’s VA examination) of the right knee reveals enthesophyte of anterior superior right patella (bone spur). The VA examiner opined that the Veteran’s right-knee disorder was less likely than not (less than 50 percent) incurred in or caused by (the) onset during either period of service (October 1992 to October 1995, and May 1997 to May 1999) or is otherwise related to service during service. In her rationale, she explained her opinion with the following points. “During service, condition was acute only. There is no evidence of chronicity of care. A nexus has not been established.” Although the Veteran sought medical attention for right-knee pain in June 1995, March 1998 and January1999, “[t]he C-file is silent for right knee treatment until [August] 2014.” She further noted Osgood-Schlatter’s disease, a childhood disease, was noted in January 1999 and observed, “Osgood-Schlatter’s disease in adulthood can lead to bone growth (enthesopathy) and a visible bump where the tendon attaches to the bone. The Veteran has a bone spur present to the right knee,” identified on that day’s examination. She further concluded that the right-knee disorder “existed prior to military service [and] was not aggravated beyond its natural progression by military service.” The September 2019 VA examination’s opinion is largely based on the STRs for concluding the Veteran has a pre-existing disorder, but, once again, most of the in-service treatment notes do not state with absolute conviction whether the right-knee disorder is Osgood-Schlatter’s disease and cannot confirm the suspicions of the treatment providers because the Veteran’s prior medical records were unavailable. To the extent the September 2019 VA examiner’s opinion and examination remarks use the in-service treatment records as support, they too do not rise to the level of clear and unmistakable evidence of a pre-existing disorder and the absence of aggravation. However, the Board’s inquiry does not end here. Because the presumption of soundness is not rebutted, the claim is treated as a simple claim for service connection. Wagner v. Principi, at 1096. As stated at the beginning of this decision, to prevail on the issue of service connection, there must be (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 in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Turning again to the in-service record, it shows the Veteran presented in January 1993 complaining of right-knee pain for one day. He reported he had fallen the previous morning and struck his knee on a stone. The examiner assessed the Veteran with a contusion. In June 1995, complained of a lump on his right knee for one week. The examiner noted the “palpable enlargement” of the right tibial tubercle, he found tenderness to palpation over the inferior patellar tendon and assessed the Veteran with inferior patellar tendonitis. Several days later in June 1995, the Veteran presented complaining of a “knot” on his right knee for the past 1½ weeks, after colliding with another soldier. The examiner noted the enlarged right-tibial tubercle, he found tenderness to palpation and his assessment stated to rule out a fracture. In December 1997, the Veteran received a provisional diagnosis of right-knee pain. In October 1998, the Veteran was put on to a permanent physical profile, identifying various activities from which the Veteran was now precluded because of right-knee pain, as well as right-wrist pain. The post-service record shows, when presenting to his private treatment provider in April 2013 for right-leg pain, the Veteran’s report was noted as, “For the last month, he has also noticed pain on the outside of right hip and in his right knee.” However, in reporting his past medical history, the Veteran made no mention of right-knee pain or a right-knee injury. In a September 2013 visit to his private treatment provider, the Veteran reported “a chronic history of right hip pain with radiation to his right knee. Pain began years ago when he was in the military, and has worsened over the years. During his last visit he was ordered a hip x-ray which showed degenerative changes to the right hip.” The treatment provider assessed the Veteran only with “Joint Pain, Localized in The Hip.” The Veteran presented at VA in August 2014 with right-knee pain, also reported by him as right-leg pain, with numbness and tingling on his right side, to include right hip, right wrist and right knee. He reported to one treatment provider that he had injured his knee during active service and has had pain since. On examination, the treatment provider found good range of motion, some crepitus and no instability. She assessed the Veteran with both right-hip and right-knee arthralgia, as well as obesity. In the period from December 2014 through September 2019, the Veteran was followed for right-knee pain at VA, with the above assessment and prescriptions for over-the-counter medications and eventually the use of a knee brace, which had positive results. In a January 2020 physical therapy follow-up at VA, the treatment provider’s provisional diagnosis was right-knee pain and right-knee pain, with radiation to the right hip. Included in the note were the findings of a November 2019 x-ray, which revealed bulky, right distal patellar tendon enthesopathy and/or non-fragmented hypertrophic osseous changes of the right anterior tubercle; mild-to-moderate/moderate medial tibiofemoral joint space loss, with a recommendation for correlation for right medial meniscus pathology; and no definite stress fracture, acute depressed or displaced fracture was seen. The treatment provider issued a cane to the Veteran. Physical examination at VA in May 2020 showed for both knees ‘[n]o obvious deformity or misalignment.” The Veteran was assessed with “right knee pain, suspect meniscal pathology” and was advised of “significant wear obesity has on joints.” The foregoing shows during active service separate and distinct trauma events, such as in January 1993, when the Veteran reported falling on a stone, causing right-knee pain for at least one day. Then there are no reports and complaints of right-knee pain for approximately 2½ years when, in June 1995, the Veteran presented with a right-knee problem after “colliding” with another soldier. After the passage of another approximately 2½ years, the Veteran received a December 1997 diagnosis of right-knee pain, but it is not until March 1998 that the Veteran again complains of right-knee pain in connection with another fall. Looking again to the September 2019 VA examiner’s opinion, the first observation in her rationale is that the right-knee disorder was “acute” only, meaning a sudden onset, of short duration and being the opposite of chronic. She adds, “There is no evidence of chronicity of care,” once again, indicating the absence of any ongoing disorder requiring repeated or routine treatment. Nonetheless, the Board is well aware that after March 1998, the Veteran’s reports to his in-service treatment providers that the pain was ongoing now for months. The Veteran testified in the June 2018 Board hearing that, after medical discharge from active service, he self-treated with over-the-counter medications, heating pads, muscle rub ointment, and a knee brace. He did not seek professional medical treatment or prescription medications. He was uncertain when he had ultimately sought treatment and stated it was when he got adequate medical insurance, which he further stated could have been in 2000, 2003, 2004, or 2005. However, he underwent a medical examination on entry to a police academy in the state of Florida, he was able to complete training and he did so wearing the knee brace. However, the foregoing indicates not just the absence of treatment or “chronicity of care,” as the September VA examiner put it, but more pertinently, it suggests the absence of symptomatology, both of which are not exhibited in the record by medical evidence for approximately 15 years after medical discharge from active service. As just stated, the Veteran’s own testimony shows he was able to pass a police academy physical examination and complete a training curriculum while wearing a brace. However, the Board cannot discern a reasonable and plausible connection between the assertion that a right-knee disorder was caused by active service and the further assertion of the existence of a disorder so severe as to prevent work performance, which otherwise would seem to impel a reasonable person to seek treatment not 15 years later, but directly after service or in the years following. Based on this foundation, the Board finds the Veteran’s lay evidence overall to be inconsistent. The record shows that it is not until April 2013, when presenting to his private treatment provider with right-leg pain, that the record reflects any post-service care or treatment for the right knee. Significantly, the Veteran himself reported at that time he had only noticed pain on the “outside” of his right hip and right knee “[f]or the last month.” Moreover, as stated above, the Veteran did not report to his treatment provider of a past medical history of right-knee pain or a right-knee injury. The April 2013 private treatment visit and the September 2013 visit show the Veteran’s preoccupation was rather with his right hip. In fact, in the latter visit the Veteran reported his disorder as right-hip pain with radiation to his right knee. He had only a hip x-ray at the April 2013 visit and the assessment for the September 2013 visit was stated only as “Joint Pain, Localized in The Hip.” Ultimately, he presented to VA in August 2014, reporting right-knee pain, approximately one month before filing his substantive appeal to the Board. The Board here will address the assertions in the Veteran’s December 2020 Brief, in which the Veteran first contends that June through September 2013 private treatment notes made no mention of Osgood-Schlatter’s disease in its diagnostic impression and the September 2019 VA examiner in turn did not address this absence of such a finding, thereby making the September 2019 VA examination inadequate for not addressing this “conflicting” evidence. However, the April 2013 private treatment note was for the Veteran’s complaint of leg pain. He reported associated symptoms of “hip pain, thigh pain and knee pain.” The Veteran also reported a prior six-month history of right-sided groin pain. He reported that he had been informed it might be due to a hernia. The Veteran in his further reports made no mention of a prior medical history for right-knee pain or injury. He was assessed with “joint pain.” The treatment provider ordered an x-ray for that day, but only for the right hip, indicating, “likely to be muscular.” The June 2013 private treatment visit which followed was for an initial evaluation for hip. In the September 2013 follow-up, the Veteran presented with a complaint of left-knee pain for the last year. He also reported that it was right-hip pain which radiated into his right knee. The Veteran was again assessed with “Joint Pain. Localized In The Hip.” The foregoing private treatment record from April to September 2013 indicates the dominating preoccupation of the Veteran and his treatment providers was his right hip. Although Osgood-Schlatter’s disease is not mentioned, this not inconsistent with what is apparent from this record, that other segments of the right-lower extremity received very little reporting by the Veteran or attention by his treatment providers. The Board concludes, as probably did the September 2019 VA examiner, that there was nothing here to note. The Brief further asserts that November 2019 x-ray findings in a January 2020 VA physical therapy state: “Bulky right distal patellar tendon enthesopathy and/or non-fragmented hypertrophic osseous changes of the right anterior tubercle,” thereby, as with the 2013 private treatment notes above, showing that the x-ray findings, too, make no “mention or diagnosis” Osgood-Schlatter’s disease. The Board does not agree. The x-ray findings quoted above in fact readily comport with the September 2019 VA examiner’s observation in the rationale for her opinion that “Osgood-Schlatter’s disease in adulthood can lead to bone growth (enthesopathy) and a visible bump where the tendon attaches to the bone. The Veteran has a bone spur present to the right knee….” Both the September 2019 VA examiner’s statement and the November 2019 x-ray findings make reference to the same word, enthesopathy. In short, a “[b]ulky right distal patellar tendon enthesopathy” and the “hypertrophic osseous changes of the right anterior tubercle” mean what the September 2019 VA examiner said---- the Veteran has a “bump” on his right knee--- as characteristic of the symptomatology of Osgood-Schlatter’s disease. As a factual determination by the Board, the diagnoses are essentially the same. The Veteran and his representative next state the September 2019 VA examiner, after noting the Veteran’s reports of pain, weakness and exacerbation by both sitting and movement, responded negatively in the examination report to the question of whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time. From this, they contend that the entire September 2019 VA examination is inadequate, being based on inaccurate factual premises and therefore is of no probative value. The Board again does not agree. The point of contention regarding whether there is significant limitation of functional ability with repeated use over a period of time does not speak directly to the issue of service connection, as it addresses only current function for the purpose of VA adjudication of a disability evaluation and the rating which subsequently would be assigned, but it offers no evidence of a causal link on a direct or secondary basis of the current disorder to an event, injury or illness occurring in the past during active service. Consequently, as discussed above, the Board has taken from that examination report what is informative and legally relevant for its factual determinations for the purposes of adjudication of service connection. Therefore, these two arguments just discussed do not provide a basis on which to remand for another VA examination, as there is sufficient competent medical evidence on file for a decision on the claim for service connection. See 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). It is not entirely clear to the Board but the Veteran and his representative appear to be putting forth an alternative argument that in-service duties, training and tasks in fact worsened pre-existing Osgood-Schlatter’s disease, the diagnosis for which the Veteran was medically discharged. The Brief notes the in-service diagnoses and further notes that the Veteran was informed that it was a pre-existing childhood disorder. “However, due to the constant running[,] marching and his injury during military service[,] he was given a medical discharge due to his diagnosis of Osgood Schlatter’s disease.” If this is indeed the intended argument in the Brief, the Board first notes there is no specific evidence show that training and duties worsened the disorder beyond is natural progression. If the Board were pursuing the rebuttal of the presumption of soundness, its burden of proof would be to show the lack of aggravation. However, in the context of a straightforward service-connection claim, the burden is now on the Veteran to show medical evidence of aggravation beyond that which could be expected in the progression of the disorder. VA will not concede service connection on a secondary basis due to aggravation unless a baseline level of severity of the disability prior to the current severity can be established by medical evidence for the purpose of comparison. See 38 C.F.R. § 3.310 (b). The absence of treatment for approximately 15 years suggests that the ongoing right-knee pain in active service after March 1998 resolved at some point, just as earlier acute right-knee traumas each had resolved prior to December 1997. There is no medical evidence of an existing right-knee disorder from February 1999, the date of medical discharge, until April 2013 and even later to August 2014, when VA treatment began. Additionally, it was in the period of August 2014 through at least May 2020 that the Veteran was repeatedly diagnosed with obesity and advised of its “wear” on the knee joints. The record offers no medical evidence otherwise to support a direct causal relationship of the Veteran’s current right-knee disability to active service or the worsening of that disability by activities or events during active service. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection on any basis. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2019). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 126–27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2018). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran’s disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as “pyramiding,” must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the “pain must affect some aspect of ‘the normal working movements of the body such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while “pain may cause a functional loss, pain itself does not constitute a functional loss,” and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 2. Entitlement to an increased disability evaluation in excess of 10 percent and to an effective date earlier than July 5, 2012 for assignment of the 10 percent disability evaluation for service-connected right-wrist disorder. This claim has been characterized in the Veteran’s December 2020 Appellate Brief as “[a]n earlier effective date for the 10 percent evaluation for mild degenerative changes, right CMC [carpal metacarpal] joint, right wrist.” VA records have referred to this claim as entitlement to an increased disability evaluation, with no mention of an earlier effective date. On July 5, 2012, the Veteran contacted the Agency of Original Jurisdiction (AOJ) with a request to file a claim for an increased evaluation for his service-connected degenerative arthritis of the right wrist. For the purposes of affording the Veteran every opportunity to maximize the benefits he seeks, the Board will address both issues. The date of claim is July 5, 2012. A September 2020 rating decision assigned a 10 percent rating for painful motion of the wrist under 38 C.F.R. § 4.59, allowing consideration of functional loss due to painful motion to be rated at the minimum compensable rating for the affected disability. The Board will proceed with this appeal based on the assumption that the Veteran continues to seek a higher rating. An October 2020 rating decision granted the earlier effective date of July 5, 2012, the date of claim. The period for the Board’s consideration of relevant evidence begins approximately one year prior to July 5, 2012. In accordance with 38 C.F.R. §§ 4.1, 4.2 and Schafrath v. Derwinski, 1 Vet. App. 589 (1991), the Board has reviewed the service medical records and all other evidence of record pertaining to the history of the Veteran’s service-connected disability. However, the Board is of the opinion that this case presents no evidentiary considerations, except as noted below, that would warrant an exposition of the remote clinical history and findings pertaining to the disability at issue. Additionally, the Board has found nothing in the historical record that would lead to the conclusion that the current evidence of record is not adequate for rating purposes. The medical evidence of record shows the Veteran is right-hand dominant. The Veteran’s right-wrist disorder is rated under Diagnostic Code 5003-5215. A hyphenated diagnostic code is used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned; the additional code is shown after the hyphen. Put simply, the diagnosis of the disorder is arthritis under Diagnostic Code 5003 and the nature and effects of the disorder are limitation of motion of the right wrist, under Diagnostic Code 5215. Diagnostic Code 5003 specifies that 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, Diagnostic Codes 5003. If the limitation of motion is noncompensable under the appropriate diagnostic codes, a rating of 10 percent may be applied to each such major joint or group of minor joints affected by limitation of motion. Id. The limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. Id. For purposes of rating disability from arthritis, VA regulations consider major joints to be the shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45 (f). Pursuant to Diagnostic Code 5215, a maximum 10 percent rating is warranted where palmar flexion of the wrist is limited in line with the forearm, or where dorsiflexion is less than 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5215. As stated above, the Veteran has already been assigned a 10 percent rating for painful motion. However, the Board will look to related or analogous diagnostic codes, once again, to afford the Veteran the opportunity to achieve the maximum benefits permitted under regulation. For example, Diagnostic Code 5010 provides rating criteria for arthritis due to trauma, substantiated by x-ray findings. Although service connected for mild degenerative changes in the right wrist, the Veteran reported to the September 2019 VA examiner that the onset of the disorder was during active service, as playing sports and he injured his right wrist. However, Diagnostic Code 5010 directs that the disorder be rated “as arthritis, degenerative.” This sends the rater or adjudicator back to Diagnostic Code 5003, under which, as discussed above, the Veteran is already rated at 10 percent for painful motion of his single, major wrist joint and no additional 10 percent rating is allowed, as the symptomatology for painful motion and pain from arthritis are identical and an “extra” 10 percent rating would therefore be impermissible “pyramiding.” The 20 percent rating offered under the diagnostic code requires a diagnosis of arthritis in two or more joint or joint groups. Diagnostic Codes 5212 and 5213 require impairment of the radius and the ulna or impairment of supination and pronation. In short, these are forearm disorders and are therefore not applicable. However, higher ratings may be assigned for wrist disability under Diagnostic Code 5214, under which the Veteran’s major or dominant right wrist will receive a 30 percent rating for favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 40 percent rating is assigned where there is ankylosis of the wrist in any other position, except favorable and a 50 percent rating is warranted when there is unfavorable ankylosis in any degree of palmar flexion or with ulnar or radial deviation. A note included in Diagnostic Code 5214 states that extremely unfavorable ankylosis will be rated as loss of use of the hands under Diagnostic Code 5125. See 38 C.F.R. § 4.71 (a), Diagnostic Codes 5214, Note. Only the September 2019 VA examination for wrist conditions provides relevant findings for a possible increased rating. In that examination, the VA examiner diagnosed degenerative arthritis and mild degenerative changes, right CMC joint, right wrist. On examination, she made a finding of no right-side ankylosis. Without a finding of ankylosis, there is no higher rating available to the Veteran under Diagnostic Code 5214 and there are no other applicable diagnostic codes or any which offer a higher disability rating. The Board has carefully considered the Veteran’s detailed testimony at the June 2018 Board hearing, in which he stated his right-wrist disorder causes great pain when using his firearm and actually caused a failure to qualify with that firearm, thereby precluding promotion. He added that he misses an average of a day of work per month due to pain. As stated above, VA, in addition to applying the schedular criteria, may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). Moreover, “pain must affect some aspect of ‘the normal working movements of the body such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. However, when granted a compensable rating at 10 percent in the September 2020 rating decision, as stated above, this rating was awarded under 38 C.F.R. § 4.59, allowing consideration of functional loss due to painful motion to be rated to the minimum compensable rating for the affected disability. Although the September 2019 VA examiner did not find pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, as factors not considered in the rating criteria, she did find functional loss or functional impairment of the joint consistent with the Veteran reports to her, noted as “[r]ight wrist arthritis causes difficulty with lifting 20 pounds or more. There is difficulty carrying and firing his gun. The Veteran is unable to play sports or be physically active. The current symptoms limit the Veteran from performing at his highest potential on the job.” Therefore, the subsequent assignment of the compensable rating 10 percent under 38 C.F.R. § 4.59 has adequately addressed pain affecting “some aspect of ‘the normal working movements of the body such as ‘excursion, strength, speed, coordination, and endurance,’” as defined in 38 C.F.R. § 4.40. Turning to the issue of an earlier effective date, the effective date for an increased evaluation for a service-connected disorder is generally the date the claim was received or when entitlement arose, whichever is later. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o)(1). However, compensation can also be awarded up to one year before the date of claim, provided the claim for an increased disability rating was received within one year of the increase in disability, as shown by the evidence. That is to say, the effective date of such an increase would then be the date the increase was “factually ascertainable.” If the increase occurred more than one year prior to the claim, the increase is effective on the date of claim. If the increase occurred after the date of claim, the effective date is the date of increase. 38 U.S.C. § 5110 (a), (b)(2); 38 C.F.R. § 3.400 (o)(1)(2). See also Dalton v. Nicholson, 21 Vet. App. 23, 31-32 (2007); Harper v. Brown, 10 Vet. App. 125 (1997). The AOJ has already assigned the effective date of July 5, 2012, the date of claim. However, the record provides no medical evidence for right-wrist disorder in the year preceding that date. Therefore, regardless of whether any increase is shown in the record prior to that one-year period before date of claim, as a matter of law, the date of claim remains the only effective date available to the Veteran. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claims for an increased disability evaluation in excess of 10 percent and for an effective date earlier than July 5, 2012. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. REASONS FOR REMAND Entitlement to an increased disability evaluation in excess of 10 percent for service-connected left-hand disorder, to include fracture of the third metacarpal. The Veteran’s left-hand disorder, to include fracture of the third metacarpal, is rated under Diagnostic Code 5229, providing a sole 10 percent rating for limitation of motion of the index or long finger. However, an October 2020 rating decision awarded a 10 percent under 38 C.F.R. § 4.59 for functional loss due to painful motion. The only relevant related or analogous diagnostic code is Diagnostic Code 5226, which provides a sole rating of 10 percent for ankylosis of the long finger, whether favorable or unfavorable. 38 C.F.R. § 4.71a, Diagnostic Code 5226. There are no findings in the record for left-middle-finger ankylosis. If there were, the 10 percent rating would be unavailable as impermissible “pyramiding,” However, Diagnostic Code 5226 provides a Note, which directs the rater or adjudicator to consider also whether evaluation of the finger disability as an amputation is warranted or to consider whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. 38 C.F.R. § 4.71a, Diagnostic Code 5226, Note. Additionally, an exception to the prohibition on “pyramiding” ratings one upon the other allows for separate ratings to be assigned for distinct disabilities resulting from the same injury, so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14. As the record shows a series of left-hand findings, specified in the directives below, which might be relevant to the above considerations in the Note to Diagnostic Code 5266 and the exception to “pyramiding,” remand is therefore necessary for a VA medical opinion as to whether the Veteran’s service-connected left-hand disorder, to include fracture of the third metacarpal, meets any of the above criteria. The matters are REMANDED for the following action: 1.Arrange for a review of the claims file by a VA examiner with an appropriate specialty for producing findings for hand and finger. The complete electronic claims file must be made available to the examiner in conjunction with the examination. The examiner should detail all findings. If the examiner first concludes that an in-person examination of the Veteran is necessary, arrange for that examination. The examiner is requested to render an opinion or opinions addressing the following: (a) Whether there is limitation of function of the Veteran’s left-middle finger as an amputation is warranted. (b) Whether there is limitation of function of the finger resulting limitation of motion of other digits or interference with overall function of the left hand. The Board directs the examiner’s attention to the following: On examination during the September 2019 VA examination for hand and finger conditions, left-hand range of motion measurements were all normal. However, the September 2019 VA examiner found pain on examination causing functional loss, pain during finger flexion, evidence of pain with the use of the hand, and there was objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. The September 2019 VA examiner found pain significantly limits functional ability with repeated use over a period of time, resulting in constant pain in the left hand that causes the Veteran to decrease movement. The Veteran denied flare-ups. In regard to whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time, the Veteran reported to the September 2019 VA examiner there is constant pain in his left hand which causes the Veteran to decrease movement during repeated use over time. In a September 2015 VA primary care physician note, the Veteran reported he is service connected for a “hand injury,” adding that it “cramps up” sometimes. The opinion or opinions rendered by the examiner must be accompanied by a rationale, by which conclusions are supported by references to and discussion of findings on examination (if deemed necessary), to clinical findings in the medical evidence of record and/or to accepted medical literature. The examiner is also requested to comment on all relevant opinions in the record. The examiner is further requested to acknowledge, address, consider, and discuss all lay statements of the Veteran, most particularly, his testimony at the June 2018 Board hearing, his lay statements accompanying his October 2013 Notice of Disagreement (NOD) and September 2014 Veterans Appeals Form 9, as well as the Veteran’s reports to treatment providers, as they appear throughout the record. The Board urges the examiner to note that opinions rendered without addressing and discussing the lay evidence of the Veteran will be deemed insufficient for VA adjudication purposes. 2. After completing the above development and any other indicated development, the AOJ is requested to readjudicate the claim, with specific consideration given to (1) the criteria of the additional considerations in the Note to Diagnostic Code 5226, discussed above, (2) to whether evidence indicates a separation and distinct disability of the left finger and/or left hand, as an exception to the prohibition of “pyramiding” and (3) whether, given those findings, there is a basis for an extraschedular evaluation, to include a referral to the Director of the Compensation Service. If the benefits sought are not granted, provide the Veteran and his representative with a Supplemental Statement of the Case and allow an appropriate opportunity to respond before returning the case to the Board. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Franke, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.