Citation Nr: 21062189 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-35 440 DATE: October 6, 2021 ORDER Entitlement to a disability rating in excess of 20 percent for service-connected left ankle instability, status-post stabilization surgery is denied. Entitlement to a disability rating of 10 percent, but no higher, for service-connected left knee disability with painful motion is granted. Entitlement to a disability rating of 20 percent, but no higher, for service-connected left knee instability from January 17, 2011 is granted. Entitlement to service connection for a closed head injury is granted. FINDINGS OF FACT 1. The Veteran's service-connected left ankle instability, status-post stabilization surgery more nearly approximates marked limitation of motion; there is no evidence of ankylosis or symptoms producing the functional equivalent of ankylosis. 2. Throughout the appeal period, the Veteran's service-connected left knee disability has been manifested by flexion limited to no less than 55 degrees with pain, and extension to zero degrees. 3. Throughout the appeal period, the Veteran's service-connected left knee disability has been manifested by moderate lateral instability. 4. The Veteran's closed head injury is proximately due to his service-connected left ankle and left knee disabilities. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 20 percent for service-connected left ankle instability, status-post stabilization surgery have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, Diagnostic Code 5271. 2. The criteria for a disability rating of 10 percent for left knee disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71, 4.71a, DC 5003, 5260, 5261. 3. The criteria for a disability rating of 20 percent, but no higher, for the service-connected instability of the left knee are met from the date of claim, January 17, 2011. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5257. 4. The criteria for service connection for a closed head injury as secondary to service-connected left ankle and left knee disabilities are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1986 to May 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO), which denied a rating in excess of 20 percent for service-connected left ankle disability and a rating in excess of 10 percent for service-connected left knee disability. The rating decision also denied entitlement to service connection for a closed head injury. The Veteran filed a notice of disagreement (NOD) in January 2013 and a statement of the case (SOC) was issued in May 2017. He perfected a timely appeal in July 2017. In February 2020, the Veteran presented sworn testimony during a videoconference hearing, which was chaired by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. In a November 2020 Board decision, the claims on appeal were remanded for further evidentiary development. As will be detailed below, review of the record reflects substantial compliance with the Board's Remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). A supplemental statement of the case (SSOC) was issued in June 2021. The Veteran's VA claims file has been returned to the Board for further appellate proceedings. In a June 2021 rating decision, the RO assigned a separate 10 percent rating for service-connected left knee disability from April 1, 2021. The Veteran has not expressed satisfaction with the assigned disability ratings for the left knee disability; this matter thus remains in appellate status. See AB v. Brown, 6 Vet. App. 35, 38 (1993) (when a veteran is not granted the maximum benefit allowable under the VA Schedule for Rating Disabilities, the pending appeal as to that issue is not abrogated). The November 2020 Board decision also remanded claims of entitlement to service connection for posttraumatic stress disorder (PTSD), acquired psychiatric disability to include pain disorder and mood disorder, right shoulder impingement syndrome, right elbow disability, cervical spine disability, lumbosacral spine disability, and lower extremity numbness and pain, as well as entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU). In an April 2021 rating decision, service connection was granted for disabilities of the cervical and lumbar spine, as well as radiculopathy of the left upper extremity and the right and left lower extremities. In a June 2021 rating decision, service connection was granted for right elbow degenerative arthritis, right shoulder impingement, and PTSD with other specified depressive disorder; entitlement to a TDIU was granted from January 17, 2011 (the duration of the appeal period). The appeals in these matters have accordingly been resolved. See Grantham v. Brown, 114 F.3d 1136 (Fed. Cir. 1997) (where an appealed claim for service connection is granted during the pendency of the appeal, a second NOD must thereafter be timely filed to initiate appellate review of "downstream" issues such as the compensation level assigned for the disability or the effective date of service connection). Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating 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. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claims. In all cases, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr, at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. In this function, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam) (table); see Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probative value of evidence in light of its inherent characteristics in its relationship to other items of evidence"). The Board has considered all evidence of record as it bears on the issues before it. See 38 U.S.C. § 7104(a) ("Decisions of the Board shall be based on the entire record in the proceeding and upon consideration of all evidence and material of record"); 38 U.S.C. § 5107(b) ("Secretary shall consider all information and lay and medical evidence of record in a case"). Although the Board has an obligation to provide reasons and bases supporting these decisions, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the Veteran's appeal. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the 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 absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant 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. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. 1. Entitlement to a disability rating in excess of 20 percent for service-connected left ankle instability, status-post stabilization surgery. In the instant case, the Veteran's service-connected left ankle instability, status-post stabilization surgery is rated at 20 percent under DC 5271 throughout the appeal period. During the pendency of this appeal, the provisions of 38 C.F.R. § 4.71a were amended, effective February 7, 2021. 85 Fed. Reg. 76,453, 76,464 (Nov. 30, 2020), revised, 85 Fed. Reg. 85,523 (Dec. 29, 2020), revised, 85 Fed. Reg. 8142 (Feb. 4, 2021). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. The Board will consider the Veteran's claim under both the old and new rating criteria, and the more favorable criteria will be applied. If the new criteria are more favorable, they will only be applied from February 7, 2021, when the regulations became effective. The Veteran's left ankle disability is rated under DC 5271, which pertains to limitation of motion of the ankle. Under both the former and amended versions of DC 5271, a 10 percent evaluation is assigned for moderate limitation of the ankle, and a maximum 20 percent evaluation is assigned for marked limitation of motion. 38C.F.R. § 4.71a, DC 5271. Under the version of the diagnostic code in effect prior to February 7, 2021, marked and moderate were undefined. The terms "marked" and "moderate" were not otherwise defined in the VA rating schedule and appear to have no commonly accepted medical definition. Therefore, the Board finds it appropriate to utilize definitions provided by a general-purpose dictionary. See Terry v. Principi, 340 F.3d 1378, 1382-83 (Fed. Cir. 2003) (in the absence of an express definition, words are given their ordinary meaning). According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Marked" means "having a distinctive or emphasized character." See www.merriam-webster.com/dictionary/marked. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a ; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Under the amended version of DC 5271, moderate was defined to mean less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, and marked was defined to mean less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. Normal range of motion of the ankle is 20 degrees of dorsiflexion and 45 degrees of plantar flexion. 38C.F.R. §4.71a, Plate II. Ankylosis is defined as immobility and consolidation of a joint due to disease, injury, or surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992). Diagnostic Code 5270 assigns a 20 percent evaluation for ankylosis of the ankle in plantar flexion, less than 30 degrees. 38 C.F.R. § 4.71a, DC 5270. A 30 percent evaluation is assigned for ankylosis of the ankle in plantar flexion, between 30 and 40 degrees, or in dorsiflexion, between zero and 10 degrees. A 40 percent evaluation is assigned for ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with an abduction, adduction, inversion or eversion deformity. Diagnostic Code 5272 assigns a 10 percent evaluation for ankylosis of the subastragalar or tarsal joint in good weight-bearing position, and assigns a 20 percent evaluation for ankylosis of the subastragalar or tarsal joint in poor weight-bearing position. 38 C.F.R. § 4.71a, DC 5272. Diagnostic Code 5273 assigns a 10 percent evaluation for malunion of the os calcis or astraglus with moderate deformity, and assigns a 20 percent evaluation with marked deformity. 38 C.F.R. § 4.71a, DC 5273. Diagnostic Code 5274 assigns a 20 percent evaluation for astragalectomy. 38 C.F.R. § 4.71a, DC 5274. Loss of use of a foot is rated at 40 percent under Diagnostic Code 5167, which includes a note that the loss of use of a foot is also entitled to special monthly compensation (SMC). Similarly, amputation of the forefoot, proximal to the metatarsal bones (more than one-half of metatarsal loss) is rated at 40 percent under DC 5166, which also includes eligibility for entitlement to SMC. 38 C.F.R. § 3.350(a)(2); 4.63; 4.71a, DCs 5166, 5167. Thus, in addition to benefits under the schedular criteria set out in 38 C.F.R. § 4.71a, loss of use of the foot also warrants entitlement to compensation under the SMC regulations set forth in 38 C.F.R. § 3.350. Historically, the Veteran was service connected for left ankle disability in an April 2004 rating decision, which granted a 10 percent rating from September 9, 1999. A July 2006 rating decision assigned a temporary total evaluation for left ankle stabilization surgery from February 17, 2006 to May 1, 2006. In a January 2010 rating decision, the RO increased the assigned evaluation for the Veteran's left ankle disability to 20 percent from May 1, 2006. In January 2011, the Veteran filed a claim of entitlement to a TDIU, which led the RO to consider whether an increased rating was warranted for the Veteran's left ankle disability. An October 2012 rating decision denied a rating in excess of 20 percent for service-connected left ankle instability, status-post stabilization surgery, and this appeal follows. For the reasons set forth below, the Board finds that a rating in excess of 20 percent is not warranted for the Veteran's service-connected left ankle disability during the appeal period. The Veteran was afforded a VA examination in January 2010 at which time the examiner noted the Veteran's report of chronic daily left ankle pain at 7/10 in severity. The Veteran indicated that his left ankle pain improves to 6/10 with medication. He explained that the ankle stabilization surgery helped with instability and rolling of his ankle, but "the pain has become constant." The Veteran described left ankle swelling if he walks more than 20 to 25 yards. He cannot stand on his left ankle for more than two to five minutes. Physical examination of the left ankle did not reveal any deformity, giving way, instability, or incoordination. The Veteran exhibited pain, stiffness, weakness, and decreased speed of joint motion of the left ankle. He denied flare-ups. The Veteran had an antalgic gait. The examiner indicated that the Veteran had left ankle tenderness with pain at rest. Range of motion testing revealed dorsiflexion to 50 degrees, and plantar flexion to 20 degrees. There was objective evidence of pain with repetitive motion. There was additional limitation of plantar flexion to 10 degrees after repetitive motion testing. There was pain across the dorsum of the left foot and lateral ankle. X-ray of the left ankle revealed, "[p]ostoperative change, otherwise negative examination." The examiner diagnosed the Veteran with left ankle chronic instability with history of stabilization surgery and residual pain and decreased range of motion. The examiner reported that the Veteran's left ankle disability impacts his occupational activities; specifically, "[d]ecreased mobility, problems with lifting and carrying, lack of stamina, weakness or fatigue, decreased strength, [and] pain." The Veteran was afforded another VA examination in March 2011 at which time the examiner noted the Veteran's report of continued daily left ankle pain with a baseline of 7/10 in severity. Pain was increased with walking and standing. The Veteran reported that he is able to walk only 20 to 25 yards without having to stop and rest. The examiner did not document range of motion measurements as to the left ankle. However, the examiner confirmed a continuing diagnosis of left ankle chronic instability with history of surgical stabilization with residual pain and decreased range of motion. The Veteran was next afforded a VA examination of his left ankle in September 2012. He reported chronic left ankle instability. The Veteran reported that his left ankle disability is essentially unchanged from his March 2011 VA examination. He denied flare-ups of left ankle symptomatology. Range of motion testing revealed plantar flexion to 35 degrees with pain at 30 degrees and dorsiflexion to 15 degrees with pain at 10 degrees. There was no additional limitation of motion on repetitive use testing. The Veteran exhibited less movement than normal and pain on movement in the left ankle. There was localized tenderness/pain on palpation. Muscle strength was intact. There was no objective evidence of left ankle joint laxity. Ankylosis of the left ankle was not shown. The Veteran did not endorse the use of assistive devices for ambulation. The examiner reported that the Veteran's left ankle disability impacts his ability to work due to decreased mobility, as well as pain. A May 2017 VA examination of the left ankle documented a lateral collateral ligament sprain of the left ankle, as well as chronic pain. The Veteran described that left ankle pain is increased upon prolonged standing and walking, as well as when walking on uneven ground. He denied flare-ups of left ankle symptomatology. Range of motion testing revealed dorsiflexion to 15 degrees and plantar flexion to 40 degrees. Pain was noted on examination, but did not result in/cause functional loss. There was pain with weight-bearing. The examiner indicated that the Veteran exhibited tenderness of the lateral aspect of the left ankle. There was no additional loss of function on repetitive motion. The examiner indicated that pain, weakness, fatigability, or incoordination do not significantly limit functional ability with repeated use over a period of time. The Veteran's muscle strength was intact. There was no atrophy or ankylosis. There was no laxity of the left ankle with objective testing. The examiner reported that the Veteran's left ankle disability does impact the Veteran's ability to work. The examiner explained, "Veteran unable to [do] physical work requiring prolonged walking or standing but can [do] sedentary employment." An x-ray of the left ankle, performed in March 2021, revealed mild degenerative change status-post ankle surgery. Pursuant to the November 2020 Board Remand, the Veteran was afforded a VA examination in April 2021. He reported that his left ankle is still unstable and rolls out. He denied flare-ups. The examiner indicated that the Veteran loses approximately one third percent of range of motion after repeated use. Range of motion testing revealed plantar flexion to 25 degrees and dorsiflexion to 10 degrees; measurements were the same on both active and passive motion. There was pain with active and passive motion, which limits use. Crepitus was exhibited in the left ankle. There was tenderness to palpation. The examiner reported that pain additionally limits plantar flexion to 10 degrees and dorsiflexion to 5 degrees with repeated use over time. The examiner stated that the Veteran did not exhibit muscle atrophy or ankylosis of the joint. Objective joint laxity testing did not document any instability. The examiner reported that the Veteran's left ankle disability does impact his ability to perform occupational tasks. The examiner explained, "[d]ue to the Veteran's pain, I do not recommend significant physical labor (i.e., construction work), but there is no restriction to physical labor of a moderate nature (department store), light office work, or sedentary employment." The examiner reported that x-ray of the Veteran's left ankle revealed mild degenerative changes status-post ankle surgery. In an April 2021 VA addendum opinion, the examiner clarified that the Veteran's "left ankle arthritis shown on the exam is considered a progression of the Veteran's service-connected left ankle chronic instability, status-post stabilization." Under both the former and amended versions of DC 5271, the Veteran's 20 percent rating is for "marked" limitation of motion under DC 5271, which is the highest disability rating available for limitation of motion of the ankle, short of ankylosis. Range of motion testing shows that the Veteran's left ankle is not fixed in plantar flexion or dorsiflexion. Similarly, lay statements do not indicate that there has been ankylosis. Moreover, there is no lay or clinical evidence suggesting that the Veteran's exhibits limitation of motion that is the functional equivalent of ankylosis. Chavis v. McDonough, 34 Vet. App. 1 (2021). For example, the evidence contains no indication of or suggestion that the Veteran has experienced complete limitation of motion of the ankle due to pain during flare-ups. The Board has considered the application of other pertinent diagnostic codes throughout the appeal period. However, the Veteran did not manifest malunion of the os calcis or astragalus, nor consolidation of either ankle and/or subastragalar or tarsal joint. There is also no basis for evaluating the service-connected left ankle disability as analogous to DC 5283 or DC 5273. The Veteran's VA examinations demonstrated range of motion of the left ankle and the Veteran has not reported the functional equivalent of ankylosis. As such, the schedular criteria for a higher rating under DCs 5270 and 5272 have not been met. He had not undergone an astragalectomy and, hence, the criteria of DC 5274 are not applicable. There is also no evidence of record to show that the Veteran's left ankle symptomatology is so severe as to be analogous to loss of use of a foot or forefoot under Diagnostic Codes 5167 and 5166 and he does not contend otherwise. As such, the Veteran is not entitled to special monthly compensation for loss of use of the foot under 38 C.F.R. § 3.350. For the foregoing reasons, the Board finds that the Veteran's service-connected left ankle instability, status-post stabilization surgery does not warrant a disability rating in excess of 20 percent at any time during the appeal period. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Entitlement to a disability rating in excess of 10 percent for service-connected hyperextended left knee. 3. Entitlement to a disability rating in excess of 10 percent for service-connected left knee instability from April 1, 2021. In this case, the RO has assigned the Veteran's left knee disability two separate 10 percent disability ratings under Diagnostic Code 5257; one 10 percent rating is assigned from September 9, 1999 and the second 10 percent rating is assigned from April 1, 2021. See the rating decisions dated April 2004 and June 2021. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). 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. Therefore, the Board will consider the Veteran's left knee claim under the old criteria prior to February 7, 2021 and both the old and revised rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. While portions of the rating schedule addressing the musculoskeletal system were revised effective February 7, 2021, Diagnostic Code 5003 was only changed to clarify that it applies specifically to degenerative arthritis. Diagnostic Code 5003 provides that degenerative arthritis that is 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. When there is no limitation of motion of the specific joint or joints that involve degenerative arthritis, DC 5003 provides a 20 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations, and a 10 percent rating for degenerative arthritis with x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. Note (1) provides that the 20 percent and 10 percent ratings based on x-ray findings will not be combined with ratings based on limitation of motion. Note (2) provides that the 20 percent and 10 percent ratings based on x-ray findings, above, will not be utilized in rating conditions listed under DCs 5013 to 5024, inclusive. When there is some limitation of motion of the specific joint or joints involved that is noncompensable (0 percent) under the appropriate diagnostic codes, DC 5003 provides a rating of 10 percent for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under DC 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. When there is limitation of motion of the specific joint or joints that is compensable (10 percent or higher) under the appropriate diagnostic codes, the compensable limitation of motion should be rated under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. Additionally, Diagnostic Codes 5260 (leg, limitation of flexion) and 5261 (leg, limitation of extension) were also not changed by the revisions to the musculoskeletal system, effective February 7, 2021. The general rating schedules for limitation of motion of the knee are set forth in 38 C.F.R. § 4.71a, DCs 5260 and 5261. Normal range of motion of the knee is to 0 degrees extension and to 140 degrees flexion. See 38 C.F.R. § 4.71a, Plate II. Under DC 5260, a 10 percent disability rating is warranted for flexion limited to 45 degrees. A 20 percent disability rating is assigned for flexion limited to 30 degrees; and a 30 percent disability rating is assigned for flexion limited to 15 degrees. Under DC 5261, a 10 percent disability rating is warranted for extension limited to 10 degrees. A 20 percent disability rating is assigned for extension limited to 15 degrees. A 30 percent disability rating is assigned for extension limited to 20 degrees. A 40 percent disability rating is assigned for extension limited to 30 degrees; and a 50 percent disability rating is assigned for extension limited to 45 degrees. See 38 C.F.R. § 4.71a. In addition, separate ratings may be assigned for compensable limitation of both flexion and extension. See VAOPGCPREC 09-04 (separate ratings may be granted based on limitation of flexion (DC 5260) and limitation of extension (DC 5261) of the same knee joint). Prior to the regulatory change DC 5257 provided the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. As of February 7, 2021, under the amended criteria, the DC 5257 indicated that knee, other impairment of should be rated as follows: Recurrent subluxation or instability: 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, a 30 percent disability rating is warranted For one of the following a 20 percent disability rating is warranted: (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; (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider pre-scribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For 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, a 10 percent disabling rating is warranted. Patellar instability: 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 a 30 percent disabling rating is warranted. 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, a 20 disability rating is warranted. For 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 10 percent disability rating is warranted. Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Diagnostic Codes 5258 and 5259 were not changed by the revisions to the musculoskeletal code. DC 5258 provides that a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. 38 C.F.R. § 4.71a, DC 5258. DC 5259 provides that a 10 percent rating is warranted for symptomatic removal of semilunar cartilage. 38 C.F.R. § 4.71a, DC 5259. In this matter, the Veteran was awarded service connection for hyperextended left knee in an April 2004 rating decision; a 10 percent rating was assigned from September 9, 1999 based upon instability. In January 2011, the Veteran asserted a claim of entitlement to a TDIU and the matter of entitlement to an increased rating for the Veteran's left knee disability was also developed at that time. The increased rating claim was denied in an October 2012 rating decision. This appeal follows. As indicated above, in a June 2021 rating decision, the RO assigned a separate 10 percent rating for left knee instability from April 1, 2021, the date of the most recent VA examination. Thus, as indicated above, the RO has coded both separate assigned disability ratings under Diagnostic Code 5257. To this end, it is settled law that a single disability is not entitled to more than one disability rating within the same diagnostic code unless the regulation expressly provides otherwise. See Cullen v. Shinseki, 24 Vet. App. 74, 84 (2010). As there is no regulatory provision for the assignment of separate ratings for the same knee under DC 5257, the assignment of two separate ratings under DC 5257 for left knee instability is improper. The Board will therefore consider other applicable rating criteria to determine how to appropriately rate the Veteran's service connected left knee disability. See Butts v. Brown, 5 Vet. App. 532, 538 (1993). For the reasons set forth below, the Board finds that a 10 percent disability rating, but no higher, is warranted for painful motion under DC 5260 and a 20 percent disability rating, but no higher, is warranted for instability under DC 5257 from January 17, 2011 (the date of the increased rating claim). Here, the Veteran was afforded a VA examination in March 2011 at which time the examiner noted the Veteran's report of left knee pain at a baseline of 7/10 in severity. The Veteran indicated that his pain increased upon walking and standing. He is able to walk only 20 to 25 yards without having to stop and rest. The Veteran indicated that his knee pain decreases to 5/10 with sitting. There was no deformity, giving way, instability, pain, stiffness, weakness, incoordination, or decreased speed of joint motion. The Veteran denied episodes of dislocation or subluxation. He also denied flare-ups of left knee symptomatology. The Veteran is unable to stand for more than a few minutes, and is unable to walk more than 20 to 25 yards. He has an antalgic gait. Physical examination of the left knee revealed crepitus, tenderness, pain at rest, and subpatellar tenderness. Range of motion testing documented flexion to 140 degrees and extension to zero degrees. There was pain on repetitive motion. The examiner indicated that flexion was additionally limited to 120 degrees after three repetitions. The examiner diagnosed the Veteran with left ankle chronic instability with history of surgical stabilization with residual pain and decreased range of motion, as well as left knee internal derangement. A September 2012 VA examination of the left knee documented flexion to 125 degrees without pain and extension to zero degrees without pain. There was no additional limitation of motion on repetitive use testing. The Veteran reported that his left knee is essentially unchanged from the last VA examination. The Veteran endorsed flare-ups of left knee symptomatology and stated, "[i]t's difficult to walk during a flare-up." The examiner indicated that there was less movement than normal, pain on movement, and disturbance of locomotion. There was crepitus on motion of the knee. The examiner indicated that the Veteran has pain to palpation/tenderness of the left knee. Muscle strength was intact. There was no objective evidence of left knee instability. The Veteran denied history of recurrent patellar subluxation or dislocation. The examiner indicated that the Veteran has no meniscal condition. The Veteran's left knee disability has no impact on his ability to work; specifically, decreased mobility and pain. The Veteran was afforded another VA examination in May 2017 at which time the examiner confirmed a continuing diagnosis of hyperextended left knee. The Veteran reported chronic daily pain increased with prolonged walking, standing, and stair climbing. Range of motion testing revealed flexion to 130 degrees and extension to zero degrees. Pain was noted on examination, but does not result in/cause functional loss. There was no evidence of pain with weight-bearing. The examiner noted the Veteran's localized patellar tenderness and crepitus. There was no additional limitation of motion on repetitive use testing. The examiner indicated that pain, weakness, fatigability, and incoordination do not significantly limit functional ability with repeated use over a period of time. Muscle strength was intact. There was no atrophy or ankylosis of the left knee. The Veteran denied recurrent subluxation and lateral instability. There was no recurrent effusion or objective evidence of joint stability on testing. The examiner indicated that the Veteran's left knee disability does impact his ability to work; specifically, the "Veteran [is] unable to [do] physical work requiring prolonged walking and standing, but he can [do] sedentary work." Pursuant to the November 2020 Board Remand, the Veteran was afforded a VA examination in April 2021. The examiner diagnosed the Veteran with hyperextension of the left knee. The Veteran denied flare-ups of left knee symptomatology. However, the examiner noted that the Veteran loses approximately one half of his range of motion after repetitive activity. The Veteran endorsed a history of instability; specifically, he "has instability at times with weight-bearing." He also reported recurrent effusion several times per week. The examiner noted that pain limits use of the Veteran's left knee. Range of motion testing revealed flexion to 110 degrees with pain and extension to zero degrees; passive measurements were the same as active. There was no crepitus present. However, the left knee was tender to palpation. The examiner reported that pain limits the Veteran's functional ability with repeated use over time. The examiner estimated that flexion is reduced to 55 degrees and extension to zero degrees. There was no atrophy or ankylosis. There was no evidence of recurrent patellar instability. The Veteran reported that he wears a knee brace for ambulation. The examiner stated that the Veteran does not have a meniscal condition. The examiner reported that Lachmann's examination and anterior draw testing revealed 1+ instability at the anterior cruciate ligament; all other ligaments showed no laxity. The examiner reported that x-ray of the left knee showed ongoing mild degenerative changes, ongoing loos body suprapatellar pouch with small effusion, and no acute fracture. The examiner indicated that the Veteran's left knee disability does impact his ability to perform occupational tasks. The examiner explained, "[d]ue to the Veteran's pain, I do not recommend significant physical labor (i.e., construction work), but there is no restriction to physical labor of a moderate nature (department store), light office work, or sedentary employment." In an April 2021 VA addendum opinion, the examiner stated that the Veteran's left knee arthritis shown on examination is considered a progression of his hyperextended left knee. Based on the evidence of record, the Board finds that, rather than the 10 percent rating assigned for left knee instability from April 1, 2021, the Veteran's left knee disability is more appropriately assigned a 10 percent rating based upon pain with limitation of motion under Diagnostic Code 5260 from the date of his increased rating claim, January 17, 2011. The medical evidence of record, including VA examinations and treatment records demonstrates, at worst, 55 degrees of flexion and zero degrees of extension in the left knee with pain throughout motion. Such findings warrant noncompensable disability ratings under DC 5260 and 5261. However, the Veteran has reported that he experienced painful motion in his left knee, which has been documented upon VA examinations throughout the duration of the appeal period. See the VA examinations dated March 2011, September 2012, May 2017, and April 2021. In fact, as specifically noted by the March 2011 and April 2021 VA examiners, the Veteran's left knee flexion is additionally limited by pain with repetitive motion and repeated use over a period of time. Accordingly, in light of the noncompensable limitation of motion with severe pain and limitation of motion, a 10 percent rating is warranted. In this regard, the Board finds that the evidence supports a finding that the Veteran experiences symptoms which are the equivalent of flexion limited to 45 degrees. The medical evidence does not, however, document flexion limited to 30 degrees or less or symptoms which more nearly approximate that limitation of motion; as such, a rating in excess of 10 percent is not warranted under DC 5260. Critically, functional loss must be rated under the diagnostic code pertaining to limitation of motion of the affected joint, pursuant to 38 C.F.R. § 4.40; Schafrath v. Derwinski, 1 Vet. App. 589, 592 (1991) (noting that functional loss due to pain is to be rated at the same level as where motion is impeded); DeLuca v. Brown, 8 Vet. App. 202, 205-06 (noting that the disabling effect of painful motion must be considered when rating joint disabilities) (1995); Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (stating that functional loss caused by pain must be rated at the same level as if that functional loss were caused by some other factor that actually limited motion)); c.f., Petitti v. McDonald, 27 Vet. App. 415 (2015). Hence, there is no basis upon which to find additional limitation due to functional factors. See 38 C.F.R. §§ 4.40, 4.45; DeLuca, 8 Vet. App. at 202; Mitchell, 25 Vet. App. at 32. As indicated above, the Veteran's functional impairment and impaired motion with repeated use over time is contemplated in the now assigned 10 percent rating. He nevertheless does not meet the criteria for the assignment of a separate disability rating for limitation of flexion or extension in his left knee under VAOPGCPREC 09-2004, VAOPGCPREC 23-97, or VAOPGCREC 9-98. As indicated above, the Veteran is assigned a separate 10 percent rating for lateral instability of the left knee pursuant to DC 5257. However, the Board finds that a 20 percent rating is warranted for left knee instability throughout the appeal period. In this regard, the Veteran has repeatedly reported left knee instability with the use of a left knee brace, which the medical evidence shows was prescribed by his VA treatment providers. See the VA treatment records dated August 2000, September 2019, and March 2021. VA examiners have consistently documented diagnoses of hyperextended left knee and have noted the Veteran's report of instability in his left knee. Specific findings of mild or slight instability in the left knee 1+ (0-5mm) were documented by the April 20121 VA examiner. Notably, the Veteran's medical history indicates that he experienced a fall at work in December 2007, which occurred, in part, as a result of buckling of his left knee. This finding has been conceded by the AOJ. See the Veteran's NOD dated January 2013; see also the rating decision dated April 2021. Accordingly, the Board concludes that the medical and lay evidence is sufficient to find moderate instability in the left knee throughout the appeal period. The Board thus finds that a separate rating of 20 percent, but no higher, is warranted for the Veteran's left knee disability under DC 5257 from January 17, 2011. The Board has considered whether a higher rating would be warranted, including under the revised DC 5257 (in effect from February 7, 2021). To this end, the Board recognizes that the April 2021 VA examiner reported that stability testing revealed 1+ ACL laxity. The evidence additionally shows that the Veteran has been prescribed the use of a brace for ambulation. See the VA treatment records dated August 2000, September 2019, and March 2021. Accordingly, under the revised DC 5257, a 20 percent rating, but no higher, would be warranted from February 7, 2021. 38 U.S.C. § 5110(g). This is consistent with the 20 percent rating the Board is assigning herein. Critically, however, there is no documentation of an unrepeated or failed complete ligament tear; moreover, no evidence of patellar instability has been shown. Additionally, no clinician has characterized the Veteran's instability as more than moderate and the clinical findings and the Veteran's testimony indicate that his symptoms do not rise to the level of severe, as that adjective is used in the every day, common sense meaning. As such, a rating in excess of 20 percent is not warranted under either version of DC 5257. A 30 percent disability rating may be assigned for ankylosis at a favorable angle in full extension, or in slight flexion between zero and 10 degrees. 38 C.F.R. § 4.71a, DC 5256. However, as indicated above, none of the other examination and treatment records contained in the claims file documents ankylosis of the left knee or symptoms more nearly approximating ankylosis. As such, the Board finds that a higher disability rating under DC 5256 is not warranted at any time during the appeal period. The Board has also considered whether DC 5055 (knee replacement) is applicable in this matter. However, a total knee replacement was not performed in the left knee; as such, DC 5055 is not for application. In sum, the Board has considered the entire record, including the Veteran's reported symptomatology and the objective clinical evidence. For the reasons set forth above, the Board finds that a disability rating of 10 percent, but no higher, is warranted under DC 5260 from January 17, 2011 (the date of the increased rating claim). The Board also finds that a 20 percent rating, but no higher, is warranted for left knee instability under DC 5257 from January 17, 2011. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a closed head injury, claimed as secondary to service-connected left ankle disability. Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). In this matter, the Veteran asserts entitlement to service connection for a closed head injury, which he contends was incurred as a result of a December 2007 fall caused by his service-connected left ankle and left knee disabilities. See the Veteran's NOD dated January 2013; see also the February 2020 Board hearing transcript. At the outset, the Board recognizes that the Veteran's service treatment records (STRs) show he was involved in a fist fight in August 1991 in which he sustained cuts and bruises. However, there is no documentation of a head injury at that time and the Veteran's STRs are otherwise negative for any indication of an in-service head injury. Also, the record does not show that the current closed head injury is causally related to an in-service disease or injury. The Veteran does not contend otherwise. Rather, he claims service connection on a secondary basis. For the reasons set forth below, the Board finds that service connection for a closed head injury as secondary to service-connected left ankle and left knee disabilities is warranted. Private treatment records dated in September 2007 show that the Veteran was involved in a motor vehicle accident (MVA) in April 2007 in which he sustained a closed head injury with post-traumatic headaches, decreased short term memory, and tinnitus. Emergency treatment records dated in December 2007 show that the Veteran was treated for another head injury after he rolled down a flight of stairs while at work. He was noted to have landed on his right shoulder and head area. Treatment records show that the Veteran complained of head, back, and right shoulder pain at the time of the fall. The Veteran had a quantitative electroencephalogram (EEG) in December 2008, and a private neurologist determined that the results were abnormal and that the brain injury discriminate was positive for a closed head injury with a 90 percent accuracy. A March 2008 private psychological evaluation documented the Veteran's report of a December 2007 work altercation in which he sustained a head injury. The treatment provider diagnosed the Veteran with cognitive disorder, not otherwise specified (NOS) and mood disorder, NOS, secondary to multiple reported closed head injuries. The private psychologist opined, [B]ased upon the absence of significant psychiatric symptoms or treatment prior to the industrial accident, the patient's specific symptom pattern, and the temporal relationship between the onset of psychiatric symptoms and the injury, it is this psychologist's professional opinion that the work-related accident is considered to be more than 50 percent the direct and proximate cause of the patient's current psychological symptomatology. A computerized tomography (CT) scan of the brain in March 2009 was negative for abnormalities. A July 2009 private psychiatric evaluation noted that the Veteran is diagnosed with cognitive disorder, NOS, which the treatment provider found was secondary to multiple closed head traumas including the 2007 MVA, as well as the subsequent 2007 workplace fall. The Veteran submitted an October 2009 independent medical evaluation in which the private evaluator opined, "I suspect that his closed head injury is manifesting the primary symptoms of mild-to-moderate depression with rather severe anxiety and loss of impulse control and rather intense anger." The evaluator diagnosed the Veteran with cognitive disorder, NOS, and mood disorder, NOS, secondary to multiple reported closed head trauma. Private treatment records dated in October 2010 documented the Veteran's report that he was thrown down a flight of stairs while at work and sustained injuries to his neck and low back. The Veteran reported memory, concentration, and vision changes. The treatment provider indicated that he treated the Veteran in December 2007, and he also experienced a MVA in April 2007. The treatment provider diagnosed the Veteran with closed head injury with headaches, dizziness, tinnitus, memory loss, diplopia, and blackouts. The treatment provider stated that the injuries the Veteran sustained in the April 2007 MVA "had essentially resolved at the time of the new injury." Magnetic resonance imaging (MRI) of the Veteran's brain conducted in November 2010 revealed normal results. In his January 2011 claim, the Veteran reported that, in December 2007, when employed as a corrections officer, he was involved in an incident in which an inmate pushed him. The Veteran attempted to regain his footing by planting his feet; however, his left ankle rolled and his left knee buckled causing him to fall down a flight of eighteen metal stairs. A VA medical opinion was obtained in September 2012 at which time the examiner opined that the Veteran's closed head injury was not incurred as a result of his active duty service. In his January 2013 NOD, the Veteran asserted that the closed head injury and orthopedic injuries sustained in the December 2007 accident were directly caused by his left ankle and left knee buckling, which caused him to fall down the stairs. In an April 2013 report, Dr. G.W., a neurologist, indicated that the Veteran is currently diagnosed with a closed head injury with post-traumatic headaches, decreased short-term memory, and tinnitus, which was incurred as a result of instability of his left knee and left ankle. The Veteran was afforded a VA traumatic brain injury (TBI) examination in May 2017 at which time the examiner reported that the Veteran does not have a diagnosed TBI. As to the question of nexus, the VA examiner opined, "[i]t is less likely than not that the Veteran sustained TBI of any severity due to his accident 12/6/07." The examiner stated that there is no documentation in the records at the Veteran suffered any alteration, loss of consciousness, posttraumatic amnesia, or focal neurological findings. The examiner then indicated that the records "are also silent for any closed head injury at the time of the accident." The examiner further stated, "[t]here is no documentation of any headaches or other neurological symptoms following the Veteran's 12/6/07 accident therefore it is less likely than not that the Veteran sustained any residual neurological symptoms due to this accident." The examiner opined, "[m]ore likely than not, the Veteran's complaint of short-term memory difficulties, confusion, irritability, temper outbursts, crowd avoidance, low frustration tolerance is due to PTSD, anxiety, or a combination of these factors." The examiner additionally noted, "[t]here is also no evidence of a neurological etiology for the Veterans' subjective complaints of confusion, imbalance or dizziness." The examiner reiterated, "[t]he Veteran's fall 12/06/07 does not meet clinical criteria for TBI of any severity nor is there any documentation at the time of the accident. I disagree with Dr. W.'s assertion that the Veteran's quantitative EEG is diagnostic of a closed head injury. A diagnosis of closed head injury or TBI is made primarily on clinical grounds and is not diagnosed by any particular diagnostic test." At the February 2020 Board hearing, the Veteran testified concerning the head injury he sustained as a result of the workplace fall in December 2007. He described continuing headaches, dizziness, and other psychological and orthopedic symptomatology following the fall. Pursuant to the November 2020 Board Remand, a VA medical opinion was obtained in April 2021. The VA examiner determined that the Veteran sustained a mild TBI as a result of the April 2007 MVA. The examiner further stated, "[i]t is as least as likely as not that the Veteran developed emotional, behavioral signs/symptoms due to this injury." The examiner explained that treatment records show that the Veteran developed headaches, short-term memory impairment, emotional and behavioral symptoms due to this injury. The VA examiner reported that, regarding the December 2007 injury, "there is no documentation of any loss, altered consciousness, posttraumatic amnesia or focal neurological symptoms." (Continued on the next page) Notably, in rating decisions dated April 2021 and June 2021, the RO granted service connection for disabilities of the neck, lumbar spine, right elbow, and right shoulder, as well as PTSD and other specified depressive disorder as secondary to the December 2007 fall caused by the Veteran's service-connected left ankle and left knee disabilities. As such, the RO has conceded that the Veteran's December 2007 workplace fall was proximately caused by his service-connected left ankle and left knee disabilities. The Board has weighed the probative evidence of record including the March 2008, October 2009, October 2010, and April 2013 private medical opinions, the May 2017 and April 2021 VA medical opinions, as well as the April 2021 and June 2021 rating decisions, and finds that the evidence is at least in equipoise as to whether the Veteran suffered from a closed head injury as a result of the December 2007 fall, which was caused by his service-connected left ankle and left knee disabilities. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran's favor and find that the evidence supports the grant of service connection for a closed head injury. See 38 U.S.C. § 5107. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. K. Buckley, 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.