Citation Nr: 21065842 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 16-12 168 DATE: October 27, 2021 ORDER An increased rating of 100 percent for bipolar II disorder is granted, effective November 6, 2016. An increased rating of 40 percent, but no higher, for chronic lumbosacral strain (low back disability) is granted, effective April 15, 2014. A compensable rating prior to June 9, 2021, and greater than 20 percent thereafter, for radiculopathy of the right lower extremity associated with a low back disability is denied. A compensable rating prior to June 9, 2021, and greater than 20 percent thereafter, for radiculopathy of the left lower extremity associated with a low back disability is denied. A disability rating greater than 30 percent for limitation of extension of the left knee is denied. A separate disability rating of 10 percent, but no higher, for limitation of flexion of the left knee is granted, effective April 15, 2014. A separate disability rating of 10 percent, but no higher, for instability of the left knee is granted, effective February 18, 2020. A disability rating greater than 20 percent for limitation of extension of the right knee is denied. A separate disability rating of 10 percent, but no higher, for limitation of flexion of the right knee is granted, effective April 15, 2014. A separate disability rating of 10 percent, but no higher, for instability of the right knee is granted, effective February 18, 2020. A disability rating of 30 percent, but no higher, for gastroesophageal reflux disease (GERD) is granted, effective February 18, 2020. Service connection for Parkinsonism is granted. REMANDED The issues of (1) entitlement to a disability rating greater than 30 percent for postural tremor, left hand, and (2) entitlement to a disability rating greater than 20 percent for postural tremor, right upper extremity, are remanded. FINDINGS OF FACT 1. Beginning November 6, 2016, the Veteran's bipolar II disorder symptoms were productive of total occupational and social impairment. 2. The Veteran's low back disability limited forward flexion of the thoracolumbar spine to 30 degrees or less during the claim period. However, the Veteran's low back disability did not produce unfavorable ankylosis of the entire thoracolumbar spine or any incapacitating episodes during the claim period. 3. Radiculopathy of either lower extremity as due to the Veteran's service-connected low back disability was not diagnosed prior to June 9, 2021. Since that date, the evidence of record indicates that the Veteran's bilateral lower extremity radiculopathy was most analogous to moderate incomplete paralysis of the sciatic nerve. 4. For the entirety of the claim period, the Veteran's left knee disability has been manifested by painful motion during flexion and by extension limited to 20 degrees. Additionally, beginning February 18, 2020, the Veteran's left knee disability caused slight instability. However, at no time during the claim period was flexion limited to 30 degrees or less and extension was not limited to 30 degrees or less. 5. For the entirety of the claim period, the Veteran's right knee disability has been manifested by painful motion during flexion and by extension limited to 15 degrees. Additionally, beginning February 18, 2020, the Veteran's right knee disability caused slight instability. However, at no time during the claim period was flexion limited to 30 degrees or less and extension was not limited to 20 degrees or less. 6. Beginning February 18, 2020, the Veteran's GERD produced signs and symptoms that caused considerable impairment of health. However, at no point during the claim period did the Veteran's GERD cause symptom combinations productive of severe impairment of health 7. The Veteran's April 15, 2014 claim seeking an increased rating for postural tremors also encompassed a claim for service connection for Parkinson's disease. The evidence of record indicates that the Veteran's postural tremors were signs and symptoms associated with the Veteran's now-diagnosed Parkinsonism, and that these signs and symptoms had their onset in service. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 100 percent for bipolar II disorder are met, effective November 16, 2016. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.400(o), 4.1, 4.2, 4.3, 4.7, 4.10, 4.126, 4.130, Diagnostic Code 9342. 2. The criteria for a disability rating of 40 percent, but no higher, for a low back disability are met, effective April 15, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5237 (2020). 3. The criteria for a compensable disability rating prior to June 9, 2021, and greater than 20 percent thereafter, for radiculopathy of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 4. The criteria for a compensable disability rating prior to June 9, 2021, and greater than 20 percent thereafter, for radiculopathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.123, 4.124, 4.124a, Diagnostic Code 8520. 5. The criteria for a disability rating greater than 30 percent for limitation of extension of the left knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5003-5261 (2020). 6. The criteria for a disability rating greater than 20 percent for limitation of extension of the right knee are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5003-5261 (2020). 7. The criteria for a separate disability rating of 10 percent, but no higher, for limitation of flexion of the left knee are met, effective April 15, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5260 (2020). 8. The criteria for a separate disability rating of 10 percent, but no higher, for limitation of flexion of the right knee are met, effective April 15, 2014. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5260 (2020). 9. The criteria for a separate disability rating of 10 percent, but no higher, for left knee instability are met, effective February 18, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5257 (2020); English v. Wilkie, 30 Vet. App. 347 (2018). 10. The criteria for a separate disability rating of 10 percent, but no higher, for right knee instability are met, effective February 18, 2020. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.68, 4.71a, Diagnostic Code 5257 (2020); English v. Wilkie, 30 Vet. App. 347 (2018). 11. The criteria for a disability rating of 30 percent, but no higher, for GERD are met, effective February 18, 2020. 38 U.S.C. §§ 1155, 5103A, 5107; 38 C.F.R. §§ 3.400, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.113, 4.114, Diagnostic Code 7399-7346. 12. The criteria for service connection for Parkinsonism are met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303; Grimes v. McDonough, No. 18-1017, 2021 U.S. App. Vet. Claims LEXIS 742 (Apr. 28, 2021). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1982 to September 2002. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran and his spouse testified at a Board hearing before the undersigned. A transcript of the hearing is of record. Thereafter, in November 2020, the Board found that rating reductions of the Veteran's low back and bilateral knee disabilities were improper. The Board then granted an increased rating for a left upper back scar, denied an increased rating for a chronic right great ingrown toenail, and granted entitlement to a total disability rating based on individual unemployability (TDIU). Lastly, the Board remanded the following issues for further development: (1) entitlement to a disability rating greater than 20 percent for a low back disability; (2) entitlement to increased disability ratings for a left knee disability; (3) entitlement to increased ratings for a right knee disability; (4) entitlement to a disability rating greater than 30 percent for postural tremor, left hand; (5) entitlement to a disability rating greater than 20 percent for postural tremor, right upper extremity; (6) entitlement to a disability rating greater than 10 percent for GERD; and (7) entitlement to a disability rating greater than 70 percent for bipolar II disorder. Following the Board's November 2020 decision and remand, a VA RO issued a rating decision in June 2021. In that decision, the RO: (1) increased the Veteran's low back disability rating to 40 percent, effective June 9, 2021; (2) increased the Veteran's bipolar II disorder rating to 100 percent, effective March 16, 2021; and (3) granted service connection for right and left lower extremity radiculopathy associated with the low back disability, assigning initial 20 percent ratings effective June 9, 2021. As these increases did not represent a total grant of the benefits sought on appeal for the entire claim period, the Veteran's low back and bipolar II disorder increased ratings claims remained in appellate status. AB v. Brown, 6 Vet. App. 35 (1993). Relatedly, although the Veteran was recently service connected for bilateral lower extremity radiculopathy associated with his low back disability, Note (1) to the General Rating Formula for Diseases and Injuries of the Spine directs VA to evaluate any objective neurologic abnormalities associated with a spine disability under an appropriate diagnostic code. See 38 C.F.R. § 4.71a (2020). Accordingly, the Board will evaluate whether the Veteran is entitled to increased ratings for his bilateral lower extremity radiculopathy for the entire claim periodi.e., from April 15, 2014 onward. Increased Ratings 1. Bipolar II Disorder As indicated above in the Conclusions of Law section, the Board finds that entitlement to an increased rating of 100 percent for bipolar II disorder is warranted, effective November 6, 2016. Accordingly, to this extent, the Board grants that Veteran's claim. In support of this determination, the Board first notes that the Veteran's bipolar II disorder is currently assigned staged ratings pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9342. Specifically, the Veteran's disability is rated as 70 percent disabling prior to March 16, 2021, and as 100 percent disabling thereafter. These disability ratings were assigned pursuant to the General Rating Formula for Mental Disorders. Under the General Rating Formula for Mental Disorders, a 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. Comparatively, a 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 38 C.F.R. § 4.130. Moving to the evidence of record, the Board concludes that the Veteran's bipolar II disorder caused symptoms productive of total occupational and social impairment beginning on November 6, 2016, warranting the assignment of an increased 100 percent rating under the General Rating Formula for Mental Disorders from that date onward. 38 C.F.R. § 4.130. Specifically, in VA psychiatry treatment records beginning on November 6, 2017, VA mental health providers reported that the Veteran displayed previous aggressive, violent, and homicidal behavior. In noting such behavior, the providers stated that the Veteran reported that he plotted to kill his brother, sister-in-law, and his spouse's parents. The Veteran indicated that this plotting began around 1 year prior to November 6, 2017 and the situation which spurred his planning resolved itself, so he did not follow through with his plan. The Veteran then stated that he was not ashamed to tell others about his plan and that he would not have had any remorse had he followed through with it. The Board finds that such evidence was indicative of a persistent danger of hurting others, a symptom warranting the assignment of a 100 percent rating under the General Rating Formula for Mental Disorders. 38 C.F.R. § 4.130. As the Veteran's plot to kill his relatives first manifested itself around one year prior to his November 6, 2017 VA psychiatry assessment, the Board assigns an effective date of November 6, 2016 for his increased 100 percent rating. See 38 C.F.R. § 3.400(o). However, the Board also finds that a rating greater than 70 percent is not warranted prior to November 6, 2016. 38 C.F.R. § 4.130. Specifically, during an April 2015 VA PTSD examination, the Veteran denied psychotic symptoms and the VA examiner indicated that the Veteran was neatly addressed, cooperative, oriented, and did not display evidence of any thought disorder. Additionally, the examiner remarked that the Veteran did not express any homicidal ideation, was competent to manage his own finances, and had reasonable control of his impulses. Similarly, appropriate hygiene, thought processes and content, behavior, communication skills, and a lack of homicidal or suicidal thoughts were recorded in VA mental health treatment records dated in December 2014, January 2015, February 2015, March 2015, April 2015, and June 2015. In light of this evidence of record, the Board concludes that, prior to November 6, 2016, the Veteran did not display: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. These or analogous symptoms are required for a 100 percent rating under the General Rating Formula for Mental Disorders. Id. Accordingly, entitlement to a disability rating greater than 70 percent for bipolar II disorder is not warranted prior to November 6, 2016. 2. Low Back Disability In regard to the Veteran's low back disability, the Board finds that the Veteran is entitled to an increased rating of 40 percent, but no higher, for the entire claim periodi.e., April 15, 2014 onward. Accordingly, to this extent, the Board grants the Veteran's claim. In addressing the Veteran's claim, the Board first notes that, effective February 7, 2021, VA revised the criteria for evaluating disabilities of the musculoskeletal system. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). This amendment affected the evaluations of spine disabilities. VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and subsequent to the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. In the instant case, the Board finds the pre-2021 amendment criteria more favorable to the Veteran. Accordingly, it will apply them for the entirety of the claim periodi.e., from April 15, 2014 onward. Currently, the Veteran's low back disability has been evaluated as 20 percent disabling prior to June 9, 2021, and 40 percent disabling thereafter. These ratings were assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5237. Prior to February 7, 2021, disabilities assigned Diagnostic Code 5237 were evaluated according under either the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes of the General Rating Formula for Diseases and Injuries of the Spine, whichever formula resulted in a higher rating. Here, the Board finds the General Rating Formula for Diseases and Injuries of the Spine to be more appropriate as the record does not demonstrate that the Veteran experienced any incapacitating episodes, as defined by Note (1) to the Formula for Rating IVDS, during the claim period. See 38 C.F.R. § 4.71a (2020). Under the pre-2021 amendment version of General Rating Formula for Diseases and Injuries of the Spine, a 20 percent rating was assigned when forward flexion of the thoracolumbar spine was limited between 30 and 60 degrees; or, the combined range of motion of the thoracolumbar spine was not greater than 120 degrees; or, there was evidence of 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 (2020). Next, a 40 percent rating was assigned when forward flexion of the thoracolumbar spine was limited to 30 degrees or less, or when there was evidence of favorable ankylosis of the entire thoracolumbar spine. Id. Lastly, ratings of 50 percent and 100 percent were assigned when there was, respectively, evidence of unfavorable ankylosis of the entire thoracolumbar spine or unfavorable ankylosis of the entire spine. Id. Note (5) to the pre-2021 amendment version of General Rating Formula for Diseases and Injuries of the Spine defined "unfavorable ankylosis" as a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Id. Turning to the evidence of record, the Board notes that the Veteran was provided VA examinations in October 2015 and June 2021 in regard to his low back increased rating claim. In November 2020, the Board found the October 2015 VA examination to be inadequate for adjudicative purposes with respect to its range of motion findings. The Board does not disturb this finding at this time. In reviewing the June 2021 VA examination report, the Board notes that forward flexion of the thoracolumbar spine was limited to 30 degrees during both passive and active range of motion testing. Under the pre-2021 amendment version of General Rating Formula for Diseases and Injuries of the Spine, such a finding warrants the assignment of a 40 percent rating for the Veteran's low back disability. See 38 C.F.R. § 4.71a. Although the Veteran is currently in receipt of a 40 percent rating from June 9, 2021 onward, the Board concludes that an earlier effective date of April 15, 2014the date of receipt of claimis warranted for the assignment of this 40 percent rating as the June 2021 VA examination was the only adequate one provided during the claim period. The Board finds that this assignment of an earlier effective date is consistent with VA's duty to assist and its requirement to provide adequate examinations when necessary. See 38 C.F.R. § 3.326. However, in granting an increased rating of 40 percent beginning April 15, 2014, the Board also declines to assign the next higher rating of 50 percent for any portion of the claim period. In reaching this determination, the Board notes that unfavorable ankylosisor its functional equivalentas defined by Note (5) to the General Rating Formula for Diseases and Injuries of the Spine was not indicated by either the October 2015 or June 2021 VA examiners. Additionally, unfavorable ankylosis of the thoracolumbar spine was not indicated by any VA or private provider in any treatment records associated with the Veteran's claims file. As evidence of unfavorable ankylosis is required for the assignment of the next higher disability rating of 50 percent under the General Rating Formula for Diseases and Injuries of the Spine, the Board finds that entitlement to a rating greater than 40 percent for the Veteran's low back disability is not warranted. See 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2020). 3. Bilateral Lower Extremity Radiculopathy Currently, the Veteran has been assigned noncompensable ratings for his bilateral lower extremity radiculopathy prior to June 9, 2021, and 20 percent ratings thereafter. After reviewing the evidence of record, the Board declines to assign higher disability ratings for either lower extremity for any portion of the claim period. Accordingly, the Veteran's claim is denied. In support of this determination, the Board first notes that the Veteran's right and left lower extremity radiculopathy ratings were assigned pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8520representing paralysis of the sciatic nerve. Under Diagnostic Code 8520, a 10 percent rating is assigned for mild incomplete paralysis, a 20 percent rating is assigned for moderate incomplete paralysis, a 40 percent rating is assigned for moderately severe incomplete paralysis, and a 60 percent rating is assigned for severe incomplete paralysis with marked muscular atrophy. Lastly, a maximum 80 percent rating is assigned for complete paralysis where the foot dangles and drops, there is no active movement possible of the muscles below the knee, and flexion of the knee is weakened or lost entirely. Within the context of applying Diagnostic Code 8520, the terms "mild," "moderate," "moderately severe," and "severe" are not defined. 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. Moving to the evidence of record, the Board first notes that the Veteran's radiculopathy was service-connected as associated with his low back disability. Prior to June 9, 2021the date of the Veteran's most recent VA back conditions examinationradiculopathy was not identified by any VA or private medical provider. Accordingly, the Board declines to assign compensable ratings for right and left lower extremity radiculopathy prior to June 9, 2021. See 38 C.F.R. § 3.400(o)(1). For the time period from June 9, 2021 onward, the Board notes that, during the June 2021 VA back conditions examination, the VA examiner indicated that the Veteran had radiculopathy bilaterally, characterized by symptoms of moderate intermittent pain, numbness, and paresthesias. During muscle strength testing, the Veteran displayed reduced strength in all tested areas bilaterally. Additionally, the examiner indicated that the Veteran's left calf was slightly atrophied. Further, the examiner indicated that the Veteran displayed hyperactive reflexes of both knees and decreased sensation of the thighs, knees, lower leg, ankle, feet, and toes bilaterally. Relatedly, the Veteran had a positive straight leg raising test for both legs. Lastly, the examiner clarified that the Veteran's (1) reduced muscle strength was due to his low back disability; (2) left calf atrophy was due to a combination of his low back disability and Parkinson's disease; (3) reduced reflexes were due to Parkinson's disease; (4) sensory deficits were caused by his low back disability; and (5) positive straight leg raising test results were due to his low back disability. Apart from the June 2021 VA back conditions examination report, the record does not contain any additional evidence relevant to the Veteran's radiculopathy for the period of June 9, 2021 onward. From this evidence of record, the Board concludes that the Veteran's left and right lower extremity radiculopathy is best characterized as moderate incomplete paralysis of the sciatic nerves. Under Diagnostic Code 8520, such severity warrants the assignment of 20 percent ratings for each lower extremity. See 38 C.F.R. § 4.124a. The Board declines to assign the next higher ratings of 40 percent under Diagnostic Code 8520 as the Veteran did not display significant muscle atrophy and sensory deficits for the period of June 9, 2021 onward. Such findings would reflect radiculopathy of a more substantial severity, warranting the assignment of higher 40 percent ratings under Diagnostic Code 8520. As the Veteran did not display such evidence, the Board concludes that increased ratings greater than 20 percent are not warranted in the instant case for the period from June 9, 2021 onward. 4. Left and Right Knee Disabilities In addressing the Veteran's claim for increased ratings for his knee disabilities, the Board first notes that the February 7, 2021 revision to the criteria for evaluating disabilities of the musculoskeletal system also impacted the diagnostic codes used to rate knee disabilities. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021). Similar to the low back, the Board finds the pre-amendment criteria more favorable to the Veterans and, accordingly, it will apply these criteria for the entire of the claim periodi.e., from April 15, 2014 onward. Turning to the relevant rating criteria for the knees, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5260, noncompensable, 10 percent, 20 percent, and 30 percent ratings were assigned for flexion limited to 60, 45, 30, and 15 degrees, respectively. Relatedly, in regard to limitation of extension, under the pre-amendment version of 38 C.F.R. § 4.71a, Diagnostic Code 5261, noncompensable, 10 percent, 20 percent, 30 percent, and 40 percent ratings were assigned for extension limited to 5, 10, 20, 30, and 30 degrees, respectively. Lastly, prior to the 2021 amendment to 38 C.F.R. § 4.71a, under Diagnostic Code 5257, disability ratings of 10, 20, and 30 percent were assigned for slight, moderate, or severe recurrent subluxation or lateral instability of the knee. In evaluating a disability based upon limitation of motionsuch as the kneeVA is to consider, in conjunction with the otherwise applicable diagnostic codes, any additional functional loss a veteran may have sustained by virtue of other factors as described in 38 C.F.R. §§ 4.40 and 4.45. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995). Such factors include more or less movement than normal, weakened movement, excess fatigability, incoordination, pain on movement, swelling, and deformity or atrophy from disuse. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the veteran at issue. 38 C.F.R. § 4.40; Johnston v. Brown, 10 Vet. App. 80, 85 (1997). Additionally, the intent of the rating schedule is to recognize painful motion with joint or particular pathology as productive of disability. It is the intention to recognize actually painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the veteran or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). In specific regard to rating disabilities of the knee, precedent opinions of VA's General Counsel have held that dual ratings may be given for a knee disorder, with one rating for instability (Diagnostic Code 5257) and one rating for arthritis with limitation of motion (Diagnostic Codes 5003 and 5010). VAOPGCPREC 9-98 (63 Fed. Reg. 56,704 (1998)) and 23-97 (62 Fed. Reg. 63,604 (1997)). Another such opinion held that separate ratings under Diagnostic Code 5260 (leg, limitation of flexion) and Diagnostic Code 5261 (leg, limitation of extension) may be assigned for disability of the same joint. VAOPGCPREC 9-2004 (69 Fed. Reg. 59988 (2004)). Further, in Lyles v. Shulkin, the Court of Appeals for Veterans Claims (Court) recently held that evaluation of a knee disability under the diagnostic codes for recurrent subluxation or instability; limitation of extension; or limitation of flexion does not preclude as a matter of law a separate evaluation of a meniscal disability under Diagnostic Code 5258 or 5259 the diagnostic codes for removal or dislocation of semilunar cartilage. 29 Vet. App. 107, 115-16 (2017). Accordingly, considering the above, when evaluating the Veteran's left knee disability, the Board may assign separate ratings for: (1) recurrent subluxation or lateral instability; (2) limitation of flexion; (3) limitation of extension; and (4) symptoms associated with the dislocation or removal of semilunar cartilage. Here, the Veteran is currently in receipt of 30 percent and 20 percent ratings for his left and right knee disabilities, respectively. These disability ratings were assigned pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5261 (2020) for limitation of extension. After reviewing the evidence of record, the Board declines to assign higher ratings for either knee for limitation of extension. However, the Board also finds that separate 10 percent ratings for (1) limitation of flexion, effective April 15, 2014, and (2) joint instability, effective February 18, 2020, for each knee are also warranted in the instant case. Accordingly, to this extent, the Board grants the Veteran's claim. In support of this determination, the Board first notes that the Veteran was provided VA knee conditions examinations in April 2015 and June 2021. In November 2020, the Board deemed the April 2015 examination inadequate for adjudicative purposes with respect to its range of motion findings. The Board does not disturb this finding at this time. During the June 2021 VA knee conditions examination, the Veteran reported current symptoms of pain stiffness, buckling, and giving way while walking. Additionally, the Veteran reported experiencing swelling in his knees and that knee pain made it difficult for him to sleep at night. The Veteran reported experiencing flare-ups impacting both knees, which he described as periods with increased pain, stiffness, swelling, and weakness. The Veteran indicated that his flare-ups occurred daily in the evenings, lasting several hours. During initial range of motion testing, flexion of the right knee was to 90 degrees and extension was to 5 degrees. For the left knee, flexion was limited to 90 degrees and extension was limited to 10 degrees. The examiner indicated that the same range of motion was displayed during both active and passive range of motion. The examiner also indicated that painful motion was observed during flexion and extension of the right knee and flexion of the left knee. In response to the Veteran's reports of flare-ups, the examiner estimated that, during a flare, flexion and extension of the right knee would be additionally limited to 80 and 5 degrees, respectively. Comparatively, for the left knee, flexion and extension would be additionally limited to 85 and 10 degrees, respectively. Lastly, the examiner remarked that: (1) the Veteran never was diagnosed with a meniscal condition of either knee; (2) ankylosis of either knee joint was not present; and (3) the Veteran displayed persistent instability of both knees. Separate from the June 2021 VA examination, the Board notes that, during the February 2020 Board hearing, the Veteran testified that he continued to experience bilateral knee pain. Hearing Tr. at 23-26. Additionally, the Veteran reported bilateral instability and that he had great difficulty going up and down stairs. Id. In addition to the Veteran's February 2020 Board hearing testimony and the June 2021 VA examination report, the Board notes that VA and private treatment records were associated with the Veteran's claims file. However, decreased knee range of motion, documented in terms of degrees, and knee joint instability were not noted by any medical professional during the claim period. From this evidence of record, the Board finds that entitlement to ratings greater than 30 and 20 percent, respectively, for left and right knee limitation of extension are not warranted in the instant case. Specifically, at no point during the claim period was extension to 30 degrees and 20 degrees, which is necessary for the assignment of the next higher ratings of 40 percent and under Diagnostic Code 5261. 38 C.F.R. § 4.71a (2020). Accordingly, to this extent the Veteran's claim is denied. Additionally, although flexion of either knee was not limited to at least 45 degrees during the claim period, the Veteran did display painful motion during flexion of each knee at the June 2021 VA knee conditions examination. Accordingly, the Board finds that separate 10 percent ratings under Diagnostic Code 5260 for limitation of flexion are nonetheless warranted for the entire claim period to recognize this painful motion. See 38 C.F.R. §§ 3.326, 4.59, 4.71a (2020). Lastly, the Board finds that separate ratings of 10 percent are warranted for right and left knee instability under 38 C.F.R. § 4.71a, Diagnostic Code 5257 (2020), effective February 18, 2020. In assigning these separate ratings, the Board notes that, in English v. Wilkie, the Court held that, unless explicitly contemplated, objective evidence of a symptom is not categorically more probative than lay evidence in determining whether to assign an increased rating. 30 Vet. App. 347, 353 (2018). In this case, the Veteran has provided subjective reports of knee instability, beginning at the February 18, 2020 Board hearing. The Board finds the Veteran to be credible in this regard and, accordingly, categorizes his bilateral knee instability as slight, warranting the assignment of separate 10 percent ratings under Diagnostic Code 5257 (2020) and English. The Board declines to assign the next higher ratings of 20 percent under Diagnostic Code 5257 as joint instability was not observed during any physical testing during the claim period. As such, the Board concludes that separate ratings greater than 10 percent for knee joint instability may not be assigned. 5. GERD As an initial matter, the Veteran's service-connected GERD is currently rated as 10 percent disabling under 38 C.F.R. § 4.114, Diagnostic Code 7399-7346. As the hyphenated diagnostic code indicates, the Veteran's GERD is being rated by analogy to hiatal hernia. Under Diagnostic Code 7346, a 60 percent rating is assigned for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Comparatively, a 30 percent rating is assigned for persistently recurrent epigastric distress with dysphagia (difficulty swallowing), pyrosis (heartburn), and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. Finally, a 10 percent rating is assigned for two or more of the symptoms listed in the criteria for a 30 percent rating but with less severity. After reviewing the evidence of record, the Board finds that the Veteran's GERD is entitled to an increased disability rating of 30 percent, effective February 18, 2020. Accordingly, to this extent, the Veteran's claim is granted. In support of this determination, the Board first notes that the Veteran was provided VA examinations relevant to his GERD increased rating claim in October 2015, October 2017, and June 2021. First, in October 2015, the VA examiner stated that the Veteran's GERD symptoms consisted of infrequent episodes of epigastric distress and reflux. On this occasion, the Veteran indicated that he took Pepcid daily for his reflux and that it kept his symptoms "at bay." Similarly, during the October 2017 VA examination, the VA examiner noted the following as the Veteran's symptoms of GERD: epigastric distress, reflux, and sleep disturbance. The Veteran reported that he took omeprazole for GERD and that this medication worked most of the time. Lastly, in June 2021, the Veteran reported that his GERD symptoms had increased in severity. Specifically, the Veteran stated that he was prescribed Protonix for his GERD and that he recently had his dosage increased twice. The Veteran reported current symptoms of reflux, regurgitation, dyspepsia and gas pain following large meals, and an occasional burning sensation in the throat after eating. The VA examiner indicated that the Veteran's treatment plan included continuously taking Protonix twice per day. Thereafter, the examiner indicated that the Veteran experienced the following symptoms due to GERD: infrequent episodes of gastric distress, dysphagia, pyrosis, reflux, regurgitation, and substernal pain. Lastly, the examiner remarked that the Veteran's Parkinson's disease contributed to his dysphagia. Separate from these VA examination reports of record, the Veteran testified in February 2020 that he underwent two EGDs in the past 2 years because of GERD. Board Hearing Tr. at 29-31. The Veteran then stated that while he did not vomit because of GERD, he could feel his stomach contents slowly moving up and down his throat. Id. at 31. In light of the above evidence of record, the Board concludes that, from February 18, 2020 onward, the Veteran's GERD produced symptoms that caused considerable impairment of health. Specifically, without considering the ameliorative effects of prescribed medicationssee Jones v. Shinseki, 26 Vet. App. 56, 63 (2012)the Veteran's GERD caused recurrent epigastric distress with dysphagia, pyrosis, regurgitation, and substernal pain. The presence of such symptoms warrants the assignment of an increased 30 percent rating under Diagnostic Code 7346. See 38 C.F.R. § 4.114. As the Veteran first reported worsening symptoms at his February 2020 Board hearing, the date of the hearingFebruary 18, 2020is assigned as the effective date for this increased rating. See 38 C.F.R. § 3.400(o). However, even when discounting the effects of any prescribed medications, the Veteran's GERD did not produce symptoms of vomiting, material weight loss and hematemesis or melena with moderate anemia, or any other symptom combination productive of severe impairment of health during any portion of the claim period. Accordingly, the Board concludes that a rating higher than 30 percent under Diagnostic Code 7346 is not warranted. Service Connection for Parkinson's Disease On April 15, 2014, VA received the Veteran's claim for an "increased rating based on individual unemployability." Submitted with this document was a completed VA Form 21-8940, wherein the Veteran stated that all of his service-connected disabilities prevented him from securing or following a substantially gainful occupation. The VA RO which received these documents interpreted this submission as both a claim for entitlement to a TDIU as well as a claim for increased ratings for all of the Veteran's service-connected disabilities. At the time of the April 15, 2014 claim, the Veteran was service-connected for postural tremors of the left hand and the right upper extremity. In February 2016, a VA RO issued a rating decision granting partial increases to the Veteran's service-connected tremors. However, this grant did not constitute a complete grant of the benefits sought on appeal. After VA issued a statement of the case (SOC) in February 2016, the Veteran perfected his appeal in March 2016. During the February 2020 Board hearing, the Veteran testified that he had been formally diagnosed with Parkinson's disease since the filing of his claim in April 2014. Board Hearing Tr. at 14. In response to this new information, the Board in November 2020 remanded the issues of entitlement to increased ratings for postural tremors of the left hand and right upper extremity to (1) confirm the Veteran's Parkinson's disease diagnosis, and (2) if so, distinguish whether symptoms of Parkinson's disease could be distinguished from symptoms of the service-connected postural tremors. Following the November 2020 Board remand, the Court issued a decision in the case of Grimes v. McDonough, No. 18-1017, 2021 U.S. App. Vet. Claims LEXIS 742 (Apr. 28, 2021). In Grimes the Court held that a claim for service connection may encompass a related condition that is initially referenced by the claimant but not diagnosed until later in the appeal stream, regardless of whether the claim is initially granted or denied by a VA RO. Id. at *2. The Board finds Grimes to be applicable in the instant case. Specifically, although the Veteran filed an increased rating claim regarding his postural tremors in April 2014, in January 2018, Dr. Milholland of Lake Cumberland Neurology Associates diagnosed the Veteran with Parkinsonism, unspecified Parkinsonism type. While the veteran's service connection claim in Grimes also encompassed a claim for an increased rating, here similar circumstances are presented. Specifically, the Board finds that the Veteran's postural tremor increased rating claim also encompassed a claim for service connection for Parkinson's disease despite this diagnosis arising after VA's initial adjudication of the Veteran's April 2014 increased rating claim. Consistent with the Court's discussion in Grimes, after reviewing the evidence of record, the Board finds that it need not remand the issue of service connection for Parkinson's disease for additional development. Rather, the Board finds that it may adjudicate this issue on the merits as the record has already been adequately developed. Specifically, in June 2021, the Veteran was provided a VA central nervous system and neuromuscular disease examination. After reviewing the Veteran's claims file and conducting a physical examination, the VA examiner confirmed that the Veteran did have a diagnosis of Parkinsonism. The examiner then remarked that the previous service-connected diagnoses of postural tremors of the left hand and right upper extremity were erroneous and should now be corrected to Parkinsonism, unspecified Parkinsonism with essential tremor. The examiner explained that postural tremors were mere symptoms of a correct diagnosis of Veteran's Parkinsonism. In light of the Veteran's Parkinsonism diagnosis, and VA's previous award of service connection for postural tremors due to their in-service onset and continuity, the Board concludes that service connection for Parkinsonism is warranted at this time as the Veteran's tremors were mere symptoms of this newly-established diagnosis. 38 C.F.R. § 3.303; Grimes, supra. REASONS FOR REMAND Increased Ratings for Postural Tremors of the Left Hand and Right Upper Extremity Regarding these increased rating issues, the Board finds that remand is warranted in light of the above-granted issue of service connection for Parkinsonism. Specifically, following the issuance of this decision, the Agency of Original Jurisdiction (AOJ) will issue a rating decision implementing the Board's decision. Parkinsonism is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8004 for paralysis agitans. The minimum rating for disabilities assigned Diagnostic Code 8004 is 30 percent. Additionally, VA must also analyze individual chronic symptoms associated with Parkinsonism under the appropriate diagnostic codes for that body system. See 38 C.F.R. § 4.124a. If there are identifiable symptoms that can be rated under a separate diagnostic code and the combined disability rating resulting from these symptoms exceeds 30 percent for any period, then the separate ratings will be assigned for that period in place of the minimum 30 percent rating assigned under Diagnostic Code 8004. Accordingly, the Board finds that a decision on entitlement to increased ratings for postural tremors of the left hand and right upper extremity would be premature at this time as the AOJ has not yet addressed assigning separate ratings for the full constellation of symptoms associated with the Veteran's now-service connected Parkinsonism. As such, the issues are remanded. See Harris v. Derwinski, 1 Vet. App. 180 (1991). The matters are REMANDED for the following action: Adjudicate the issues of entitlement to increased ratings for postural tremors of the left hand and right upper extremity in light of the grant of service connection for Parkinsonism. S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N.S. Pettine, 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.