Citation Nr: 21061671 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 17-25 213 DATE: October 5, 2021 ORDER Entitlement to a rating in excess of 20 percent for a cervical spine strain with intervertebral disc syndrome (IVDS) is denied. Entitlement to a rating in excess of 20 percent for radiculopathy of the upper right extremity is denied. Entitlement to a rating in excess of 10 percent for osteoarthritis of the right knee is denied. Entitlement to service connection of a gastrointestinal disability, claimed as indigestion, is denied. Entitlement to service connection of erectile dysfunction is denied. Entitlement to service connection of a left knee disability is denied. REMANDED Entitlement to service connection of a left arm disability is remanded. Entitlement to service connection of a left knee disability is remanded. Entitlement to service connection of chronic pain syndrome is remanded. Entitlement to service connection of a gastrointestinal disability, claimed as indigestion, is remanded. Entitlement to service connection of erectile dysfunction is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine disability has resulted in limitation of forward flexion to no less than 20 degrees with pain; his IVDS has not resulted in incapacitating episodes throughout the period on appeal. 2. The Veteran's radiculopathy of the upper right extremity is wholly sensory in nature with a complete disability picture that is mild in nature. 3. The Veteran's osteoarthritis of the right knee has resulted in painful flexion and extension, with flexion limited to no less than 80 degrees and complete and full extension; he has not had any medical evidence of instability or subluxation. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5237, 5243. 2. The criteria for a disability rating in excess of 20 percent for right upper extremity radiculopathy have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, DC 8510. 3. The criteria for a rating in excess of 10 percent for osteoarthritis of the right knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DCs 5003, 5257, 5260, 5261. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1985 ot October 1993, including service in the Southwest Asia Theatre of Operations during the Persian Gulf War. This matter comes before the Board of Veterans' Appeals (Board) on appeal from October and November 2016 Rating Decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). As a matter of procedural background, this appeal previously came before the Board in January 2020, at which time the Board remanded the issues remaining on appeal for further development. Also remanded at that time were claims of service connection of an acquired psychiatric disability, to include major depressive disorder, and a sleep disability (claimed as insomnia). During the pendency of the ordered development, the RO issued a rating decision in September 2020 which granted service connection of depressive disorder and insomnia disorder as a single disability. As this constituted a complete grant of those issues sought, they are no longer part of this appeal. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's cervical spine disability, entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Where, as in the case of the Veteran's right arm radiculopathy and right knee disability, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 1. Entitlement to a rating in excess of 20 percent for a cervical spine strain with intervertebral disc syndrome (IVDS) The Veteran's cervical spine strain is presently rated 20 percent disabling based on the presence of intervertebral disc syndrome (IVDS). He seeks a higher rating. The Board finds that the claim should be denied. The Veteran's cervical spine strain is presently rated under Diagnostic Code (DC) 5243, which compensates based on the presence of IVDS with incapacitating episodes. Under the applicable rating criteria, a 20 percent rating is assigned IVDS with incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks during the prior 12 months. A 40 percent rating is assigned for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. Finally, a maximum 60 percent rating is assigned for incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. An alternative method for rating a cervical spine disability falls under Diagnostic Code 5237 which rates for cervical strain, and applies the General Rating Formula for Diseases and Injuries of the Spine (the Board takes note that prior the Veteran's claim for an increased rating filed in January 2015, the Veteran's cervical spine strain was rated pursuant to DC 5237). Under that rating criteria, a 20 percent rating is assigned for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, DC 5237. A 30 percent rating is assigned for forward flexion of the cervical spine to 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine; finally, a 100 percent rating is warranted with unfavorable ankylosis of the entire spine. Id. When rating diseases of the spine, the Board is also to rate any associated neurological abnormalities separately under an appropriate diagnostic code. Id., Note (1). It is noted that the Board is addressing his right upper extremity radiculopathy separately, below. The question of service connection of left upper extremity neurological complications is addressed in the below remand. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the knee have been amended, effective February 7, 2021. Specifically, the rating code for DC 5243 was amended to clarify it should be assigned only when there is disc herniation with compression and/or irritation of the adjacent nerve root. For all other diagnoses, DC 5242 (rating based on degenerative arthritis of the spine, and applying the General Rating Formula for Diseases and Injuries of the Spine) should be applied. Notably, the rating criteria itself was not amended, but merely the description of what disabilities qualify as IVDS. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's cervical disability under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, 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 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The Veteran was initially afforded a VA examination in May 2015. At that time, cervical spine strain was diagnosed. The Veteran reported pain in his neck, going down his spine, affecting his ability to walk. He reported pain 7/10 daily with 10/10 pain during flare-ups, which occurred 1-2 times per month, lasting about a week. He reported not being able to run, jump, walk long distances, or climb stairs. He stated he needed a cane to assist with standing up. Forward flexion was to 30 degrees, with combined range of motion of 110 degrees. Pain was noted on movement, but did not cause additional loss beyond that demonstrated on the examination. No additional loss was found on repetitive use testing, or with repetitive use over time. The examination was medically consistent with the Veteran's statements describing functional loss during flare-ups. There were no muscle spasms. He showed pain and guarding along his trapezius muscle at the base of the spine causing him to protect and slow his movements. He held his head in a 5 degree kyphotic position. He could maintain a neutral cervical spine position. Muscle strength was normal. He did not have muscle atrophy. Reflexes were normal. Sensory testing was normal. No radiculopathy was found. Although IVDS was noted, no episodes required bed rest in the prior 12 months. He used a cane to ambulate. In September 2016, a new VA examination found evidence of degenerative disc disease and cervical spinal stenosis. The Veteran reported a history of neck pain beginning in 1989 with radiation down his right shoulder causing intermittent pain, numbness and tingling which radiates as far down as his wrist. Forward flexion was to 20 degrees with complete range of motion to 138 degrees with pain at the terminal points of movement. There as mild tenderness with moderate palpation over the cervical spine. He was able to perform repetitive use testing over time with no additional loss oof use. He explicitly denied flare-ups. He did not show guarding or muscle spasm. He showed less movement than usual. Muscle strength was normal throughout. He did not have muscle atrophy reflexes were normal. She showed some decreased sensation in the right forearm and hand/fingers. Radiculopathy was identified in the right upper extremity only, with moderate intermittent pain (usually dull), paresthesias and/or dysesthesias, and numbness, but no evidence of constant pain. The examiner opined that the upper right extremity radiculopathy was moderate at most. There was no ankylosis nor any functional fixation of the neck. No other neurological abnormalities were identified. He did not have IVDS. He did not use an assistive device to ambulate. Functionally, the examiner stated that the condition did not affect his ability to work. Most recently, a VA examination was conducted in March 2020. The Veteran was diagnosed with cervical spine strain with IVDS, and right upper radiculopathy. The Veteran reported no significant evaluation of his neck for several years. He had not required surgery and treated his pain with ibuprofen. The course since onset had worsened or progressed. Current symptoms were pain and numbness/ tingling. He denied flare-ups, but reported difficulty with overhead lifting and pressing. Range of motion was normal on all movements. Pain was noted but did not cause functional loss. He had tenderness over the trapezius and cervical paraspinal muscles, with 2/10 pain, which the examiner attributed to IVDS. He was able to perform repetitive use testing with no additional loss. The examination was neither medically consistent nor inconsistent with his reports of functional use over time. He explicitly denied flare-ups. No additional factors contributed to his disability. Muscle strength testing was normal throughout. He did not have muscle atrophy. Reflexes were normal throughout. The examiner found sensation to be absent in both arms, but found this to be inconsistent with the examination. Specifically, the examiner clarified that radiculopathy is not a symptom of his stroke, and therefore, the examiner was disinclined to remove it from his diagnoses. However, the strength and motor component was not distinguishable from the residuals of the unrelated stroke, thus why sensation was absent. Physical examination of the affected nerves appeared normal and were nor consistent with some of the findings which were more likely due to residuals of his stroke. He showed mild paresthesias and/or dysesthesias and numbness in both upper extremities, but no evidence of neurological pain. He did not have ankylosis or functional fixation of the neck. Although IVDS was identified, it had not resulted in any episodes of acute signs and symptoms that required bedrest in the prior 12 months. He did not use an assistive device to ambulate. No other pertinent physical findings were identified. Functionally, the cervical spine disability did not affect his ability to work. A contemporary peripheral nerve examination continued ot find right upper extremity radiculopathy as well as left upper and lower hemiparesis due to a subsequent stroke. The course of his condition was stable and his current symptoms included diffuse pain, and pain in the right shoulder due to physical therapy. The examiner found mild constant pain, paresthesias and/or dysesthesias, and numbness in the right upper extremity but no other symptoms. Muscle strength testing in the left side, was reduced but attributed to his stroke, and not to radiculopathy. Muscle strength in the right arm was normal. Muscle atrophy was noted, but was global and sue to his wheelchair-bound status. Reflexes were normal in the right arm. Again, absent sensation was reported, but was attributed to residuals of the stoke, and were nor consistent with a symptom of radiculopathy. He did not have trophic changes. He did not require the use of an assistive device. The examiner stated that the hemiparesis was due to his stroke and distinct from his radiculopathy, which pre-existed service. The radiculopathy was not a symptom of the stroke, but strength and motor components of the examination were not distinguishable from the stroke in this setting. The Board has reviewed the available private and VA treatment records but finds nothing that would specifically address the rating criteria for his cervical spine disability. Based on the available evidence, the Board does not find that a rating in excess of 20 percent is warranted for the cervical spine disability. At no point has forward flexion of the cervical spine been limited to 15 degrees or less, nor has he shown any evidence of diagnosed ankylosis or functional fixation of the cervical spine. Indeed, most recently he demonstrated complete and full motion of the cervical spine. Further, while IVDS is present, there is no evidence that it has caused 4 weeks or more of incapacitating episodes. Even considering movement in weight bearing, non-weight bearing, active or passive movement, he has not shown limitation such that a higher rating is warranted. Likewise, the Veteran has generally denied flare-ups, and even with flares early in the appeal period, he has not indicated loss of use such that a higher rating would be warranted. In short, while the Veteran does have symptoms related to his cervical spine disability, they do not meet the schedular requirements for a rating in excess of 20 percent at this time. As such, the claim for an increase beyond 20 percent is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 2. Entitlement to a rating in excess of 20 percent for radiculopathy of the upper right extremity The Veteran is service-connected for right upper extremity radiculopathy, as secondary to his service-connected cervical spine injury. He seeks a rating in excess of 20 percent for that disability. The Board finds that the claim should be denied. The Veteran's radiculopathy is rated under DC 8510, which compensates based on paralysis of the upper radicular group. Under the applicable rating criteria, a 20 percent rating is granted for mild incomplete paralysis of the upper radicular group. Moderate incomplete paralysis is awarded a 40 percent rating. Severe incomplete paralysis is granted a 50 percent rating. finally, complete paralysis, described as all shoulder and elbow movements lost or severely affected, hand and wrist movements not affected, is awarded a 70 percent rating. 38 C.F.R. § 4.124a, DC 8510. Terms such as "mild," "moderate," and "severe" are not defined by the rating schedule; rather than applying a mechanical formula, VA must evaluate all the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. The term "incomplete paralysis," with this and other peripheral nerve injuries, indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. 38 C.F.R. § 4.124a. In May 2015, a VA examination found no evidence of radiculopathy. Muscle strength was normal. He did not have muscle atrophy. Reflexes were normal. Sensory testing was normal. In September 2016 a VA neck examination identified radiculopathy in the right upper extremity. Muscle strength was normal throughout. He did not have muscle atrophy reflexes were normal. She showed some decreased sensation in the right forearm and hand/fingers. Radiculopathy was identified in the right upper extremity only, with moderate intermittent pain (usually dull), paresthesias and/or dysesthesias, and numbness, but no evidence of constant pain. The examiner opined that the upper right extremity radiculopathy was moderate at most. An associated peripheral neuropathy examination identified moderate cervical radiculopathy in the right upper extremity only. Sensory testing showed decreased (but not absent) sensation in the forearm and hand/fingers only. All other locations were normal. He did not have trophic changes. Functionally, the examiner did not find that the condition affected his ability to work. Most recently, a VA examination was conducted in March 2020. Upon examination of his neck disability, muscle strength testing was normal throughout. He did not have muscle atrophy. Reflexes were normal throughout. The examiner found sensation to be absent in both arms, but found this to be inconsistent with the examination. Specifically, the examiner clarified that radiculopathy is not a symptom of his stroke, and therefore, the examiner was disinclined to remove it from his diagnoses. However, the strength and motor component was not distinguishable from the residuals of the unrelated stroke, thus why sensation was absent. Physical examination of the affected nerves appeared normal and were nor consistent with some of the findings which were more likely due to residuals of his stroke. He showed mild paresthesias and/or dysesthesias and numbness in both upper extremities, but no evidence of neurological pain. He did not have ankylosis or functional fixation of the neck. Based on the available evidence, the Board finds that the Veteran's right upper extremity radiculopathy should be rated no greater than 20 percent disabling. At most, his condition has been sensory throughout the appeal period (indeed, in the earliest portion of the appeal period, it was not found at all). Although the examiner did find some moderate symptoms in 2016, the Board does not find that this should give rise to more than a 20 percent rating. Those symptoms were only sensory in nature and did not interfere with his ability to use the arm. Indeed, the examiner found no actual functional impact of the disability. His muscle strength and reflexes were all completely normal. And the sensory testing abnormalities only seemed to affect the forearm and hand, and did not affect the whole arm. Therefore, even presuming the Veteran's disability did show some "moderate" symptoms, when looked at as a whole, the Board does not find the Veteran's right upper extremity radiculopathy to be greater than mild in nature. This is further confirmed by the 2020 examination which also found generally normal reflexes and muscle strength with no more than some mild symptoms attributable to the radiculopathy. In fact, while sensation was absent bilaterally in the upper extremities, the examiner attributed this exclusively to residuals of his unrelated stroke, and found no evidence of a progression of his radiculopathy. As such, the Board continues to find that the Veteran's right upper extremity radiculopathy was no greater than sensory and mild throughout the period on appeal, and a rating in excess of 20 percent for the disability is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The Board notes that the question of a rating for left upper extremity radiculopathy remains on appeal and is addressed in the below remand. 3. Entitlement to a rating in excess of 10 percent for osteoarthritis of the right knee The Veteran's right knee disability, diagnosed as osteoarthritis of the right knee, is presently rated as 10 percent disabling. He seeks a higher rating. The Board finds the claim should be denied. The Veteran's right knee disability is rated under DC 5003-5260. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, DC 5003 indicates degenerative arthritis, other than post-traumatic arthritis. DC 5260 indicates a knee disability manifested by limitation of flexion. Under the applicable rating criteria, degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 pct 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. 38 C.F.R. § 4.71a, DC 5003. Under DC 5260, a noncompensable rating is granted when flexion of the knee is limited to 60 degrees. A 10 percent rating is awarded when flexion is limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees, and a 30 percent rating is assigned for flexion limited to 15 degrees or less. 38 C.F.R. § 4.71a, DC 5260. When rating based on limitation of motion, a separate rating may be assigned for knee disabilities based on limitation of flexion as well as limitation of extension of the knee if both pathologies exist. Likewise, separate ratings may be assigned based on limitation of motion, as well as instability or subluxation, if found. See VAOPGCPREC 23-97 (Multiple Ratings for Knee Disability). When extension of the knee is limited to 10 degrees, a 10 percent rating is warranted. For a rating in excess of 10 percent, the knee must be limited in extension ot 15 degrees or greater. 38 C.F.R. § 4.71a, DC 5261. Under DC 5257, a 10 percent rating for recurrent subluxation or lateral instability is assigned for a sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For a 20 percent rating, one of the following must be shown: (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Finally, a 30 percent rating is assigned for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. 38 C.F.R. § 4.71a, DC 5257. Likewise, a 10 percent rating is assigned for patellar instability, described as a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. A 20 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. Finally, a 30 percent rating is assigned for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. Id. Other ratings pertaining to the knee are available based on tibia or fibula impairment, genu recurvatum, and ankylosis, however, no such pathology is shown in this matter. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the knee have been amended. Specifically, the criteria pertaining to (1) knee instability under 38 C.F.R. § 4.71a, Diagnostic Codes (DC's) 5257 and 5262 respectively, was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's right knee disability under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. With regard to the old criteria, recurrent subluxation or lateral instability were compensated with a 10 percent rating based on slight disability. Moderate disability was awarded a 20 percent rating. Severe disability was awarded a 30 percent rating. Prior to the update, ratings based on patellar instability were nor granted. 38 C.F.R. § 4.71a, DC 5257 (prior to February 7, 2021); see 85 Fed. Reg. 76,453 (November 30, 2020). It is further noted that DC 5003 was amended to exclude post-traumatic arthritis from the ratings for degenerative arthritis. A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40 With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. Although pain may cause functional loss, pain itself does not constitute functional loss. Rather, 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 ); see also DeLuca v. Brown, 8 Vet. App. 202, 206-207 (1995). The Veteran was afforded a VA examination in September 2016. At that time, he was diagnosed with knee strain and osteoarthritis. The Veteran endorsed flare-ups, described as "the right knee just swells up." He reported that walking or prolonged standing aggravated it, as did climbing a lot of stairs. Flexion was limited to 90 degrees; extension was complete to 0 degrees. Pain was only observed on flexion and there was no evidence of pain with weight bearing. There was evidence of moderate, diffuse joint tenderness and crepitus. An additional 10 degrees of flexion was lost with repetitive use testing, and the examination was medically consistent with the Veteran's statements describing functional loss with use over time. Pain limited motion, at most to 80 degrees flexion. He had pain with prolonged sitting, standing, and walking. Muscle strength was normal on all planes of movement. He did not have muscle atrophy. There was no ankylosis diagnosed, nor any functional fixation of the joint. Joint stability testing was normal without evidence of recurrent subluxation, lateral instability or effusion. No joint instability was identified, and all stability testing showed normal findings. There was no history of patellar dislocation, shin splints, stress fractures, chronic exertional compartment syndrome or any other tibial or fibular impairments. By history, the examiner noted that a September 2016 rheumatology treatment record indicated bucking in the knee. He occasionally used a brace, and constantly used a walker to ambulate. Functionally, his ability to work was limited due to an inability to engage in prolonged standing or sitting. A new examination was conducted in March 2020. At that time, his ostearthritis of the right knee was confirmed as a diagnosis. He reported treating his knee pain with over the counter medication. He had not had any surgeries or injections in his knee. His condition was stable, and he reported a lack of feeling in the knee, most likely due to his unrelated stroke. Range of motion was completely normal, although he did show signs of pain with flexion and extension. He also showed pain with a patella grind, at 2/10 in severity. No pain was noted with weight bearing, and he did not have crepitus. No additional loss was found with repetitive use testing. The examination was neither medically consistent, nor inconsistent with the Veteran's statements of functional loss with use over time, and the examiner stated no additional loss of range of motion would be expected. The examination was not conducted during a flare up, but the examination was neither medically consistent, nor inconsistent with the Veteran's statements of functional loss during such a period of flare. No additional factors contributed to his disability. There was no diagnosis of ankylosis or functional fixation of the knee. Stability testing was normal. He did not have a meniscal condition. No other pertinent findings were reported. He did not use an assistive device to ambulate, although it is noted elsewhere that the Veteran used a wheelchair due to residuals of his stroke, and not his knee disability. The examiner noted that, functionally, his arthritis would limit his standing and walking in absence of the stroke. While the Veteran has sought treatment for his knee over the course of the appeal period, the relevant records do not include range of motion findings or other relevant data such that would apply to the rating of his right knee disability. Based on the available evidence, the Board finds that the claim for a rating in excess of 10 percent should be denied. In this regard, there is no evidence of any type of joint instability or subluxation. While he did report his knee giving out in the September 2016 report, that report was given to a rheumatologist, and not to an orthopedist treating the knee. Further, the VA examination conducted that month found no evidence of any type of instability or giving way in the knee, to include all stability testing. As such, the Board concludes that the medical evidence does not support a rating based on instability or subluxation. With regard to painful motion, he has consistently shown painful motion on flexion, although not limiting his range of motion beyond 80 degrees, which does not result in a compensable rating. Likewise, while he denied painful motion on extension at the 2016 examination, and did endorse pain with extension in 2020, his extension has always been complete and full, which also does not provide for a compensable rating. Although he has endorsed flare-ups, they result in swelling, but he has not endorsed any actual functional loss during the appeal period. In this matter, the Veteran's right knee has not been shown to warrant a compensable rating based on any limitation under any applicable diagnostic code. However, as noted above, when osteoarthritis causes painful motion, a single 10 percent rating is to be applied. Therefore, in this matter, even considering the Veteran's reports of flares, to include swelling in the knee, the maximum available rating based on the evidence of record is 10 percent. As such, the claim is denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection of a left knee disability 2. Entitlement to service connection of a left arm disability 3. Entitlement to service connection of chronic pain syndrome 4. Entitlement to service connection of a gastrointestinal disability 5. Entitlement to service connection of erectile dysfunction Inasmuch as the Board regrets further delay in the adjudication of these claims, an additional remand is necessary to ensure complete development of these claims, as previously ordered by the Board. The Veteran initially filed his claims in May 2016, claiming "Gulf War Illness" and pain in both arms due to his spine disability. In June 2016, he clarified his Gulf War claim to include, among other things, erectile dysfunction, "gastro-indigestion," and chronic pain syndrome. In its January 2020 remand, the Board specifically ordered that these disabilities be evaluated via a Gulf War examination. Additionally, the Board ordered that if specific diagnoses could not be given, the examiner should provide an opinion as to whether the Veteran's symptoms constituted a medically unexplained chronic multisymptom illness. For any diagnosed illness, the examiner was to opine as to whether the disability is causally related to any exposures in Southwest Asia. Despite the Board's specific order for a Gulf War examination, the Veteran was afforded various examinations to include individual male reproductive, neurological, intestinal, rectal, and stomach examination, with a "Gulf War" form indicating that each individual questionnaire should be reviewed. While this, alone, technically complies with the Board's order for a Gulf War examination, the Board finds the contents of those examination reports to be of limited probative value. Throughout the various examinations, the Veteran was diagnosed with left side hemiparesis, erectile dysfunction, bowel incontinence, all secondary to a stroke, which the examiner opined was not likely related to any incident of active service. Although right upper extremity radiculopathy was identified (indeed, that is already service-connected and addressed in the above decision), the examiner concluded that the left arm and knee pain was exclusively due to left-sided hemiparesis, secondary to a stroke. The Board finds these conclusions problematic. Particularly, while the record indicates that the Veteran did suffer from a stroke in approximately January 2017, that stroke post-dates the Veteran's claims. In fact, his claims of gastrointestinal issues, widespread pain, left arm pain, and erectile dysfunction, pre-date his stroke by many months, and the Veteran has submitted statements indicating the presence of widespread pain since approximately 2006-2007. Given the examiner's focus on the later stroke, this leaves the question of service connection of any disability which may have pre-existed that condition unanswered. The Board further notes that the examiner opined against service connection for the various disabilities based on the premise that the "Veteran does not relay a history that is commensurate with exposure." As noted in the Board's prior remand, the Veteran has confirmed service in the Southwest Asia theatre of operations, and therefore the Board has conceded he was likely exposed to various chemical and environmental agents as part of his service. To the extent that the examiner concluded he was not exposed to any such agents, there is no explanation for that conclusion, as that exposure has been conceded. Finally, concerning the Veteran's left knee, as was noted in the prior remand, he was previously diagnosed with a left knee strain, but a prior examination focused exclusively on the Veteran's chemical exposures, and did not discuss connection to service in general. The Board remanded that claim so that an opinion which addressed this deficiency in general could be obtained. The 2020 examiner found no current diagnosis beyond the left sided hemiparesis, and declined to give an opinion. Although there was no diagnosis at the time of the 2020 examination, there was a diagnosis of a strain during the appeal period, and an opinion must still be obtained. In light of this, the Board would request that an addendum opinion be obtained which assesses the Veteran's claims to specifically consider whether any disability existed prior to his stroke, which may either be diagnosed or considered a medically unexplained chronic multisymptom illness. For any diagnosed condition which is found to preexist his stroke, the examiner should provide an opinion with regard to whether it is related to active service, to include any exposures in Southwest Asia. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his appeal. Obtain and associate with the claims file any outstanding VA treatment records. 2. Obtain an addendum opinion from a qualified VA clinician regarding the service-connection claims on appeal. The need for a new examination is left to the discretion of the examiner. The examiner is requested to review the complete claims file and state whether the Veteran has a confirmed diagnosis to account for the following: gastro-indigestion, erectile dysfunction, left arm pain, and widespread chronic pain, which account for his claimed symptoms that pre-existed the 2017 stroke. If no diagnosis can be given for the reported symptoms prior to his stroke, but were present during the appeal period, the examiner is requested to state whether those symptoms constitute a medically unexplained chronic multisymptom illness (MUCMI). For each diagnosed condition that preexisted the 2017 stroke (and not found to be part of a MUCMI), the examiner should state whether the Veteran's disability is at least as likely as not related to any incident of active service, to include any chemical or environmental exposures during his service in Southwest Asia. The examiner is notified that the Veteran's has confirmed service in the Persian Gulf, and therefore certain exposures are conceded. Concerning the Veteran's left arm disability, the examiner is explicitly requested to state whether the Veteran has radiculopathy or another neurological disability in that arm which may be attributable to his service-connected cervical spine disability. In rendering that opinion, the examiner is requested to consider the Veteran's statements that he has similar pain in both arms, and that that pain was claimed prior to his stroke in 2017. Finally, concerning the left knee claim, although the 2020 examiner did not find any evidence of a present disability, a prior VA examination diagnosed a sprain in the left knee. The examiner is requested to opine as to whether that sprain is related to the Veteran's active service in general. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Pryce, Counsel