Citation Nr: 21066037 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 16-35 624A DATE: October 28, 2021 ORDER Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to an increased disability rating greater than 20 percent prior to June 16, 2015, and greater than 70 percent from that date, for service-connected peripheral neuropathy of the right upper extremity is denied. Entitlement to an increased disability rating greater than 20 percent prior to June 16, 2015, and greater than 60 percent from that date, for service-connected peripheral neuropathy of the left upper extremity is denied. Entitlement to an increased disability greater than 10 percent prior to June 16, 2015, and greater than 60 percent from that date, for service-connected peripheral neuropathy of the right lower extremity is denied. Entitlement to an increased disability greater than 10 percent prior to June 16, 2015, and greater than 60 percent from that date, for service-connected peripheral neuropathy of the left lower extremity is denied. Entitlement to an increased disability rating greater than 30 percent for service-connected peripheral neuropathy of the right lower extremity (femoral) is denied. Entitlement to an increased disability rating greater than 30 percent for service-connected peripheral neuropathy of the left lower extremity (femoral) is denied. FINDINGS OF FACT 1. The Veteran's right knee disability, including arthritis, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran's left knee disability, including arthritis, was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 3. During the one-year period prior to June 16, 2015, it is not factually ascertainable that the severity of the Veteran's peripheral neuropathy of the right upper extremity was manifested by more than mild incomplete paralysis of the major extremity. 4. During the one-year period prior to June 16, 2015, it is not factually ascertainable that the severity of the Veteran's peripheral neuropathy of the left upper extremity was manifested by more than mild incomplete paralysis of the minor extremity. 5. During the rating period from June 16, 2015, the Veteran's peripheral neuropathy of the right upper extremity is manifest by no more than severe incomplete paralysis of the major extremity. 6. During the rating period from June 16, 2015, the Veteran's peripheral neuropathy of the left upper extremity is manifest by no more than severe incomplete paralysis of the minor extremity. 7. During the one-year period prior to June 16, 2015, it is not factually ascertainable that the severity of the Veteran's peripheral neuropathy of the right lower extremity was manifested by more than mild incomplete paralysis. 8. During the one-year period prior to June 16, 2015, it is not factually ascertainable that the severity of the Veteran's peripheral neuropathy of the left lower extremity was manifested by more than mild incomplete paralysis. 9. During the period from June 16, 2015, the Veteran's peripheral neuropathy of the right lower extremity is manifest by no more than severe incomplete paralysis , with marked muscular atrophy, incomplete paralysis. 10. During the period from June 16, 2015, the Veteran's peripheral neuropathy of the left lower extremity is manifest by no more than severe incomplete paralysis, with marked muscular atrophy, incomplete paralysis. 11. During the period from June 16, 2015, the Veteran's peripheral neuropathy of the right lower extremity (femoral) is manifest by no more than severe incomplete paralysis. 12. During the period from June 16, 2015, the Veteran's peripheral neuropathy of the left lower extremity (femoral) is manifest by no more than severe incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. During the one-year period prior to June 16, 2015, the criteria for a disability rating in excess of 20 percent for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8513, 8514. 4. During the one-year period prior to June 16, 2015, the criteria for a disability rating in excess of 20 percent for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Codes 8513, 8514. 5. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 70 percent for peripheral neuropathy of the right upper extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8513. 6. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 60 percent for peripheral neuropathy of the left upper extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8513. 7. During the one-year period prior to June 16, 2015, the criteria for a disability rating in excess of 10 percent for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 8. During the one-year period prior to June 16, 2015, the criteria for a disability rating in excess of 10 percent for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 9. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 60 percent for peripheral neuropathy of the right lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 10. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 60 percent for peripheral neuropathy of the left lower extremity are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8520. 11. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 30 percent for peripheral neuropathy of the right lower extremity (femoral) are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. 12. During the rating period from June 16, 2015, the criteria for a disability rating in excess of 30 percent for peripheral neuropathy of the left lower extremity (femoral) are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8526. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Marine Corps from November 1966 to December 1969, including service in Vietnam. This case comes to the Board of Veterans' Appeals (Board) on appeal from decisions of the Agency of Original Jurisdiction (AOJ) dated in December 2014 and October 2015. The Veteran testified before a decision review officer (DRO) of the AOJ in August 2016, and before the undersigned Veterans Law Judge at a June 2019 hearing; transcripts of the hearings are of record. In February 2020, the Veteran appointed a new representative before VA, and the representative has submitted written argument. In July 2020, the Board remanded this case to the AOJ for additional development; the case was subsequently returned to the Board. SERVICE CONNECTION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three elements required to establish service connection are: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). 1. Service connection for a right knee disability 2. Service connection for a left knee disability The Veteran contends that he incurred bilateral knee disabilities during combat service in Vietnam, as a result of going on several reconnaissance patrols over rough and hilly terrain while carrying gear weighing about 150 pounds, and repeatedly jumping from helicopters while carrying heavy gear. See his November 1990 statement, September 1994 claim, July 2016 statement, and June 2019 Board hearing transcript. At the Board hearing, he testified that his knees began hurting in service, and he had knee problems since then. See Board hearing transcript, page 11. Alternatively, the Veteran contends that presumptive service connection under 38 C.F.R. § 3.309 (a) is warranted for gouty arthritis of the right knee and a left knee disability. See July 2016 substantive appeal. At the August 2016 DRO hearing, he reported that he was first diagnosed with gout by VA. See DRO hearing transcript, page 7. Service personnel records reflect that the Veteran served on active duty in the Marine Corps from November 1966 to December 1969, including service in Vietnam, and his primary military occupational specialty (MOS) was rifleman. He was awarded the Combat Action Ribbon, Presidential Unit Citation, and Republic of Vietnam Campaign Medal with 60 device, among other awards. Under applicable law, a Veteran who served on active duty in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, is presumed to have been exposed to an herbicide agent, absent affirmative evidence to the contrary. See 38 C.F.R. § 3.307 (a)(6)(iii). VA regulations further provide that service connection is warranted for certain specified diseases as presumptively due to herbicide agent exposure. 38 U.S.C. § 1116; 38 C.F.R. § 3.309 (e). Since gout and arthritis are not diseases presumptively associated with exposure to herbicide agents in Vietnam, service connection is not warranted on a presumptive basis under 38 C.F.R. § 3.309 (e) for these conditions. Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran has been diagnosed with arthritis of the right and left knees as evidenced by a December 1994 VA examination, VA treatment records dated in April 1998, October 2000, and November 2008, and private medical records from P.T., MD, dated in August 2011 and July 2013. Arthritis is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, arthritis of the knees was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. VA and private treatment records show the Veteran was not diagnosed with arthritis of the right knee until March 1984, or arthritis of the left knee until December 1994, decades after his separation from service and decades outside of the applicable presumptive period. Gout, with elevated uric acid shown on laboratory studies, was first diagnosed in an April 1983 report of a VA Agent Orange examination. While the Veteran is competent to report experiencing symptoms of bilateral knee pain and swelling since service, the Board finds the reports of continuity of symptomatology not credible due to internal inconsistency and inconsistency with other evidence in the record. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Such statements made for VA disability compensation purposes are of lesser probative value when in contradiction to histories he previously provided, including his previous statements made to medical providers in the course of seeking medical treatment. See Pond v. West, 12 Vet. App. 341 (1999). The Veteran's current statements are internally inconsistent with his reports in contemporaneous treatment records, which show that he initially reported the onset of right knee pain and swelling as March 1984, outside of the presumptive period, and did not report any left knee symptoms until December 1986. Service treatment records are negative for complaints or treatment of a knee injury or symptoms. In a March 1984 VA admission note, the Veteran complained of right leg (especially the knee) swelling and throbbing since the previous day, and said he had not injured it recently. He reported that he hurt his right knee in 1968 in Vietnam when he jumped from a helicopter. He did not report any left knee injury or symptoms during VA or private treatment until December 1986, despite seeking treatment for other conditions. Private medical records from Lentini Health Center and St. Mary's Hospital dated from 1985 to 1990 do not reflect complaints regarding either knee until November 1986, although they show treatment for foot and toe complaints since 1981. In February 1985, the Veteran complained of tenderness of the big toes, but did not complain of any knee symptoms. A November 1985 VA treatment note reflects that the Veteran complained of numbness of the right leg, mostly when sitting, that started one month ago, and also reported a history of an old football injury to the lateral knee. On examination, there was effusion around the right patella; the diagnosis was sub-patellar bursitis. A December 1986 private treatment note from St. Mary's Hospital reflects that the Veteran reported that he first had problems with his knees and feet in Vietnam in 1968, and had occasional light pains since then. VA outpatient treatment records dated from 1987 to 1990 reflect treatment of gout of the big toes and right knee, but do not show complaints of left knee symptoms. Private medical records from Kent Community Hospital dated from December 1990 to January 1991 reflect treatment for alcohol and substance dependence. On admission, the Veteran complained of right knee swelling and pain. He denied pain, swelling, or limitation of motion of any other joints, except for the toes and right elbow. In other words, he denied any current left knee symptoms. On discharge, in pertinent part, he was diagnosed with gout and recurrent joint effusion of the right knee, but a left knee disability was not diagnosed. The Veteran has also made conflicting statements regarding claimed in-service treatment for knee symptoms. In November 1990, he stated that during in-service hospital treatment for his feet in 1969 at a Naval Hospital in Bangor, Washington, his knees were swollen, but the swelling subsided and he did not recall any specific treatment for knee problems. In a February 1991 statement he said he was treated for his right knee and both feet in 1968 in Da Nang, Vietnam, and in 1969 at a Naval Hospital in Bangor, Washington. In his September 1994 claim, he stated that he was treated for a knee condition at a military field hospital in Da Nang in 1968 with two weeks of bed rest, and in 1969 at a Naval Hospital in Bangor, Washington. On VA examination in December 1994, the Veteran reported that he hurt his knees and feet after jumping out of helicopters in Vietnam, and had intermittent pain since then which was aggravated by his railroad work from 1970 to 1989, as he was a brakeman, an inspector, and did a lot of bull work. A November 2008 VA outpatient treatment record reflects that the Veteran reported that he had pain in his knees for years, including prior to service, while playing football in high school (when he got shots), in college, in Vietnam when he was jumping out of helicopters, and when he was working on the railroad. He reported that he had injections in his knees since his teens, and the last time was in the 1980s when he was working for the railroad. VA medical records reflect that the Veteran's knees were injured in a November 2009 motor vehicle accident in which he hit a deer at 75 miles per hour, and then complained of headaches, neck and shoulder pain, and pain and swelling in the knees, left greater than right. The diagnostic assessment was musculoskeletal pain, worse since an automobile accident. An August 2011 VA outpatient treatment record reflects that the Veteran's left knee was injured in an automobile accident in November 2009, that a magnetic resonance imaging (MRI) confirmed a meniscal tear, and the surgery was covered by his automobile insurance. The diagnostic impression was a left knee meniscal tear. Private operative reports from Dr. T. reflect that he performed a left knee arthroscopy in August 2011 and a right knee arthroscopy in July 2013. The postoperative diagnoses were left knee medial meniscus tear with underlying arthritis, and right knee medial meniscus tear with underlying arthritis and lateral meniscus tear. Subsequently, at the June 2019 Board hearing, the Veteran made conflicting statements about his claimed diagnosis of a torn meniscus of the right knee during service. He initially testified that a corpsman in Vietnam diagnosed this condition after he hurt his knee jumping out of a helicopter while carrying heavy gear, and was on bed rest in Vietnam for a torn meniscus of the knee. See June 2019 Board hearing transcript, pages 5-6. He then stated that he could not get a diagnosis from the corpsman at that time. Id., page 6. The Board notes that his testimony regarding the reason for his in-service bed rest conflicts with his July 2016 statement, in which he said he was placed on bed rest in Vietnam because he could barely walk due to very bad chafing after patrolling in monsoon season with continuous torrential rain. These multiple contradictions in his various statements to VA and medical providers reduce the credibility of his statements regarding a right or left knee injury in service and regarding continuous symptoms since service. The Veteran's more recent statements are also inconsistent with the contemporaneous medical records. Service treatment records from his period of active duty are negative for complaints or treatment of knee injuries or symptoms, including during his treatment for other conditions at NAD Bangor in 1969. Sick call treatment records from the Veteran's service in Vietnam are on file, and do not reflect complaints or treatment related to the knees, although he did receive orthopedic treatment for a right elbow injury. On separation medical examination in November 1969, his lower extremities were normal, and knee disabilities were not diagnosed. The Board acknowledges that the Veteran served in combat, and thus, the provisions of 38 U.S.C. § 1154 (b) apply, and the Board finds that his lay statements of injuring one or both knees while carrying heavy gear during combat service are consistent with the circumstances of his service. However, even assuming that a knee injury occurred, the Veteran's current assertions are not consistent with the medical records associated with the claims file or his own in-service reports regarding his health. The Veteran's service treatment records, including reports of examinations, appear to be complete and they likely would include reference to an in-service knee injury or symptoms, including by self-report at separation, if such symptoms were present. See AZ v. Shinseki, 731 F.3d 1303 (Fed. Cir. 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present). Further, while the Veteran asserts that the reported knee symptoms were manifestations of arthritis, he is not competent to determine that these symptoms were manifestations of arthritis as he has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Service connection for right and left knee disabilities may still be granted on a direct basis; however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's right and left knee disabilities and an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303. The Board notes that although the Veteran has at times reported that he had a knee condition prior to service, see, e.g., November 2008 VA outpatient treatment record, since a knee disability was not noted on service entrance medical examination in November 1966, he is presumed to have been in sound condition with regard to his knees on entry into service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). The Veteran has other bilateral knee disabilities in addition to arthritis. VA MRI scans in November 2017 showed right knee severe complex tearing of the medial meniscus and severe tricompartmental cartilage degeneration, and left knee severe complex tearing of the medial meniscus, severe tricompartmental cartilage degeneration, mucoid degeneration of the ACL, and mild patellar tendinopathy. The Veteran has since undergone left and right total knee replacements, and the November 2020 VA examiner diagnosed status post right and left total knee arthroplasty (TKA). The November 2020 VA examiner opined that the Veteran's right and left knee disabilities are not at least as likely as not related to an in-service injury, event, or disease, including jumping out of helicopters in service. The rationale was that his separation examination was negative for a knee condition. He was seen in 1987 for an aspiration to his knee due to the presence of gout to the knee. He underwent bilateral TKA due to progressive degeneration of his knee joints. He also worked for the railroad after separation from service as a maintenance engineer and had developed complaints of knee pain at that time, and there is no ongoing documentation showing that his knee condition is likely related to his time in service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Moreover, the Veteran's lay reports of in-service origins and persistence of bilateral knee symptoms since service have been deemed to lack credibility. Consequently, the Board gives more probative weight to the November 2020 VA examiner's opinion. While the Veteran believes his right and left knee disabilities are related to an in-service injury, event, or disease, including jumping from helicopters and patrolling while wearing heavy gear, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires specialized medical education, knowledge of anatomical relationships, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the probative evidence is against the claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). INCREASED RATINGS Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disability upon the person's ordinary activity, 38 C.F.R. § 4.10. The Veteran contends that a 100 percent rating is warranted for each of the following disabilities: peripheral neuropathy of the right and left upper and right and left lower extremities, femoral peripheral neuropathy of the right lower extremity, and femoral peripheral neuropathy of the left lower extremity. See October 2015 notice of disagreement. In August 2016, the Veteran's former representative contended that although there is no complete paralysis of the nerves because the Veteran does not meet the definitions in the C.F.R., he is still entitled to the highest schedular rating of 97 percent or more by using one of two methods of calculation: the combined rating under 38 C.F.R. § 4.25, and the combined rating with the bilateral factor included. The Board notes that a combined service-connected disability rating of 100 percent has been in effect since January 1999, with special monthly compensation since July 2011. This appeal arises from a June 16, 2015 claim for increased ratings for service-connected peripheral neuropathy of the bilateral upper and lower extremities. The effective date for an award of an increased rating is the date of claim, or the date entitlement arose, whichever is later. 38 C.F.R. § 3.400 (o)(1). If it is factually ascertainable that an increase in disability occurred within the one-year period prior to filing the claim, the effective date will be the date the increase was shown. 38 C.F.R. § 3.400 (o)(2). 1. Increased rating for peripheral neuropathy of the right upper extremity 2. Increased rating for peripheral neuropathy of the left upper extremity The Veteran contends that he is entitled to a higher rating for service-connected peripheral neuropathy of the right and left upper extremities because he has pain and weakness. Prior to June 16, 2015, the AOJ has rated service-connected peripheral neuropathy of the right upper extremity as 20 percent disabling, and rated peripheral neuropathy of the left upper extremity as 20 percent disabling under Diagnostic Code 8714, pertaining to neuralgia of the musculospiral nerve (radial nerve). 38 C.F.R. § 4.124a. From June 16, 2015, the AOJ has rated peripheral neuropathy of the right upper extremity as 70 percent disabling, and rated peripheral neuropathy of the left upper extremity as 60 percent disabling under Diagnostic Code 8513, pertaining to paralysis of all radicular groups. 38 C.F.R. § 4.124a. The evidence reflects that the Veteran is right-handed, and thus the right upper extremity is the major extremity. Paralysis of the radial nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8514. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8614 and 8714. Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 30 percent for the major extremity and 20 percent for the minor extremity. Severe incomplete paralysis is rated as 50 percent for the major extremity and 40 percent for the minor extremity. Complete paralysis, with drop of hand and fingers, wrist and fingers perpetually flexed, the thumb adducted falling within the line of the outer border of the index finger; cannot extend hand at wrist, extend proximal phalanges of fingers, extend thumb, or make lateral movement of wrist; supination of hand, extension and flexion of elbow weakened, the loss of synergic motion of extensors impairs the hand grip seriously; total paralysis of the triceps occurs only as the greatest rarity, is rated as 70 percent for the major extremity, and 60 percent for the minor extremity. 38 C.F.R. § 4.124a. Paralysis of all radicular groups is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8513. Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8613 and 8713. Under these criteria, mild incomplete paralysis is rated as 20 percent for both the major and minor extremity. Moderate incomplete paralysis is rated as 40 percent for the major extremity and 30 percent for the minor extremity. Severe incomplete paralysis is rated as 70 percent for the major extremity and 60 percent for the minor extremity. Complete paralysis of all radicular groups is rated as 90 percent for the major extremity, and 80 percent for the minor extremity. 38 C.F.R. § 4.124a. The words "mild," "moderate," and "severe" as used in the various Diagnostic Codes are not defined in the Rating Schedule. Regulations provide that ratings for peripheral neurological disorders are to be assigned based the relative impairment of motor function, trophic changes, or sensory disturbance. 38 C.F.R. § 4.120. Consideration is also given for loss of reflexes, pain, and muscle atrophy. See 38 C.F.R. §§ 4.123, 4.124. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating is for the mild, or at most, the moderate degree. The disability ratings for the peripheral nerves are for unilateral involvement; when bilateral, the ratings combine with application of the bilateral factor. 38 C.F.R. § 4.124a, Note at "Diseases of the Peripheral Nerves." The Note to 38 C.F.R. § 4.124a establishes a maximum disability rating for conditions that are wholly sensory, as opposed to a minimum disability rating for conditions that are more than wholly sensory. See Miller v. Shulkin, 28 Vet. App. 376 (2017). Neuritis, cranial or peripheral, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete, paralysis. The maximum rating which may be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate, or with sciatic nerve involvement, for moderately severe, incomplete paralysis. 38 C.F.R. § 4.123. Neuralgia, cranial or peripheral, characterized usually by a dull and intermittent pain, of typical distribution so as to identify the nerve, is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis. Tic douloureux, or trifacial neuralgia, may be rated up to complete paralysis of the affected nerve. 38 C.F.R. § 4.124. In January 2012, prior to the rating period on appeal, the Veteran underwent an electromyography (EMG) and nerve conduction study (NCS) of the upper and lower extremities, which showed no sensory nerve action potential (SNAP) on the left ulnar nerve. The examiner concluded that the study was compatible with mild to moderate diabetic neuropathy. Regarding impairment of motor functions, the December 2011 VA examiner indicated that muscle strength throughout both upper extremities was 4/5 (less than normal) throughout, except for grip strength, which was 3/5 (no movement against resistance). The January 2012 EMG/NCS showed normal motor nerve conduction velocity in both upper extremities. During the pendency of the appeal, on VA examination in July 2015, strength was 4/5 bilaterally for elbow flexion, elbow extension, and wrist extension. Left wrist flexion was 5/5 (normal), and right wrist flexion was 4/5. Grip and pinch strength were 3/5 bilaterally. On VA examination in November 2020, muscle strength of both upper extremities was 5/5 (normal) throughout. Regarding trophic changes, although the December 2011 VA examiner stated that there was hair loss on the legs and arms attributable to diabetic peripheral neuropathy, during the pendency of the current appeal, both the July 2015 and November 2020 VA examiners indicated that there were no trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy. Regarding sensory disturbance, on VA examination in December 2011, sensation to light touch/monofilament testing was normal in the shoulders and forearms, and decreased in the hands and fingers. There were severe paresthesias and/or dysesthesias and numbness of both upper extremities. On VA examination in July 2015, during the pendency of the current appeal, sensation to light touch/ monofilament testing was decreased in the shoulders and forearms, and absent in the hands and fingers. Vibration sensation was absent in both upper extremities. There was mild paresthesias and/or dysesthesias of both upper extremities, and moderate numbness of both upper extremities. On VA examination in November 2020, sensation to light touch was normal in the shoulders and forearms, and decreased in the hands and fingers. There were no paresthesias and/or dysesthesias of the upper extremities, and mild numbness of the upper extremities. Regarding loss of reflexes, on VA examination in December 2011, reflexes were 2+ (normal) throughout both upper extremities. On VA examination in July 2015, reflexes were 0 (absent) throughout both upper extremities. On VA examination in November 2020, reflexes were normal throughout both upper extremities. Regarding pain, on VA examination in December 2011, there was moderate constant and intermittent pain in both upper extremities. On VA examination in July 2015, there was mild constant pain and moderate intermittent pain in both upper extremities. On VA examination in November 2020, there was no constant or intermittent pain in the upper extremities. Regarding muscle atrophy, there was no muscle atrophy in either upper extremity on examinations in December 2011, July 2015, and November 2020. Regarding complete paralysis, the medical evidence, including the December 2011, July 2015, and November 2020 VA examinations, does not show complete paralysis in either the right or left upper extremities. The December 2011 examiner indicated that there was mild incomplete paralysis of the right and left radial and median nerves. The July 2015 VA examiner indicated that there was severe incomplete paralysis of the right and left radial, median, and ulnar nerves. The November 2020 VA examiner indicated that there was mild incomplete paralysis of the right and left radial, median, and ulnar nerves, and of the lower radicular group. The other nerves of the upper extremities were normal. Based on the above, the Board finds that throughout the rating period from June 16, 2015, the service-connected peripheral neuropathy of the upper extremities is primarily manifest by impairment of motor functions, sensory disturbance, loss of reflexes, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by trophic changes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to severe incomplete paralysis. Combined nerve injuries, as in this case, shall be rated by reference to the major involvement, or if sufficient in extent, consider radicular group ratings. See Note, 38 C.F.R. § 4.124a, regarding diseases of the peripheral nerves. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The evidence does not show that it is factually ascertainable that an increase in the severity of peripheral neuropathy of the upper extremities occurred within the one-year lookback period prior to filing the increased rating claim. The VA medical records during this period primarily relate to treatment for other conditions, and do not show that the disabilities increased in severity. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 70 percent for peripheral neuropathy of the right upper extremity, and 60 percent for peripheral neuropathy of the left upper extremity. In denying such ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. 3. Increased rating for peripheral neuropathy of the right lower extremity 4. Increased rating for peripheral neuropathy of the left lower extremity 5. Increased rating for peripheral neuropathy (femoral), right lower extremity 6. Increased rating for peripheral neuropathy (femoral), left lower extremity The Veteran contends that he is entitled to a higher rating for service-connected peripheral neuropathy of the right and left lower extremities because he has pain and weakness. The AOJ has rated service-connected peripheral neuropathy of the right lower extremity under Diagnostic Code 8520 as 10 percent disabling prior to June 16, 2015, and as 60 percent disabling from that date, and has rated peripheral neuropathy of the left lower extremity under Diagnostic Code 8520 as 10 percent disabling prior to June 16, 2015, and as 60 percent disabling from that date. Diagnostic Code 8520 pertains to paralysis of the sciatic nerve. 38 C.F.R. § 4.124a. From June 16, 2015, the AOJ has assigned separate 30 percent ratings for service-connected peripheral neuropathy (femoral) of the right and left lower extremities under Diagnostic Code 8526, pertaining to paralysis of the anterior crural nerve (femoral). Paralysis of the sciatic nerve is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8520. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8620 and 8720.). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Moderately severe incomplete paralysis is rated as 40 percent disabling. Severe incomplete paralysis, with marked muscular atrophy is rated as 60 percent disabling. Complete paralysis, with the foot dangles and drops, no active movement possible of muscles below the knee, flexion of knee weakened or (very rarely) lost is rated as 80 percent disabling. 38 C.F.R. § 4.124a. Paralysis of the anterior crural nerve (femoral) is evaluated in accordance with the criteria set forth in 38 C.F.R. § 4.124a, Diagnostic Code 8526. (Neuritis and neuralgia of that group are evaluated under Diagnostic Codes 8626 and 8726). Under these criteria, mild incomplete paralysis is rated as 10 percent disabling. Moderate incomplete paralysis is rated as 20 percent disabling. Severe incomplete paralysis is rated as 30 disabling. Complete paralysis, with paralysis of the quadriceps extensor muscles is rated as 40 percent disabling. 38 C.F.R. § 4.124a. Prior to the rating period on appeal, a January 2012 EMG and NCS of the lower extremities showed no sensory nerve action potential (SNAP) on the bilateral sural nerves. There was normal motor nerve conduction velocity (NCV) on all extremities, but some dispersion of compound muscle action potential (CMAP) and low amplitudes on bilateral peroneal and tibial nerves. The examiner concluded that the study was compatible with mild to moderate diabetic neuropathy. Regarding impairment of motor functions, the December 2011 VA examiner indicated that muscle strength was 4/5 (less than normal) in bilateral knee extension, and was 3/5 (no movement against resistance) in bilateral knee flexion and ankle plantar flexion and dorsiflexion. On January 2012 EMG and NCS, there was normal motor nerve conduction velocity in both lower extremities. During the pendency of the appeal, on VA examination in July 2015, bilateral knee extension and flexion were 4/5, and bilateral ankle plantar flexion and dorsiflexion were 5/5 (normal). On VA examination in November 2020, muscle strength throughout both lower extremities was normal. Regarding trophic changes, although the December 2011 VA examiner stated that there was hair loss on the legs and arms attributable to diabetic peripheral neuropathy, during the pendency of the current appeal, both the July 2015 and November 2020 VA examiners indicated that there were no trophic changes (characterized by loss of extremity hair, smooth, shiny skin, etc.) attributable to peripheral neuropathy. Regarding sensory disturbance, on VA examination in December 2011, sensation to light touch/monofilament testing and vibration was decreased in both lower extremities, while position sense was normal. There were severe paresthesias and/or dysesthesias and numbness of both lower extremities. On VA examination in July 2015, sensation to light touch/ monofilament testing was decreased in the left knee and thigh, and otherwise absent in both lower extremities. Sensation to vibration was absent in both lower extremities. There was severe paresthesias and/or dysesthesias and numbness of both lower extremities. The examiner indicated that the Veteran's peripheral neuropathy in his bilateral lower extremities has led to absent sensation to monofilament testing and vibratory sensation. On VA examination in November 2020, sensation to light touch was normal in both legs, and decreased in both feet and toes. There were no paresthesias and/or dysesthesias the lower extremities, and mild numbness of both lower extremities. Regarding loss of reflexes, on VA examination in December 2011, reflexes were 1+ (decreased) throughout both lower extremities. On VA examination in July 2015, reflexes were 1+ (decreased) in the right knee, and otherwise 0 (absent) throughout both lower extremities. The examiner indicated that the Veteran's peripheral neuropathy in his bilateral lower extremities has led to decreased reflexes. On VA examination in November 2020, reflexes were absent in both knees, and normal in both ankles. Regarding pain, in December 2011, there was severe constant and intermittent pain in both lower extremities. On VA examination in July 2015, there was moderate constant intermittent pain in both lower extremities. On VA examination in November 2020, there was no constant or intermittent pain in the lower extremities. Regarding muscle atrophy, there was no muscle atrophy in either lower extremity on examinations in December 2011, July 2015, and November 2020. Regarding complete paralysis, the medical evidence, the medical evidence, including the December 2011, July 2015, and November 2020 VA examinations, does not show complete paralysis in either the right or left lower extremities. The December 2011 examiner indicated that there was mild incomplete paralysis of the right and left sciatic and femoral nerves. The July 2015 VA examiner indicated that there was moderately severe incomplete paralysis of the right and left sciatic nerve, and severe incomplete paralysis of the right and left femoral nerve. The November 2020 VA examiner indicated that the right and left sciatic and femoral nerves were normal. There was mild incomplete paralysis of the right and left external popliteal, musculocutaneous, anterior tibial, internal popliteal, and posterior tibial nerve. Other nerves of the lower extremities were normal. Based on the above, the Board finds that throughout the rating period from June 16, 2015, the service-connected peripheral neuropathy of the lower extremities is primarily manifest by impairment of motor functions, sensory disturbance, loss of reflexes, and pain. The Board also finds that the most probative evidence of record is against a finding that the disability is manifest by trophic changes, muscle atrophy, or complete paralysis. The Board thus finds that the level of impairment is most analogous to severe incomplete paralysis. The Board has considered all other potentially applicable Diagnostic Codes, but there is no evidence showing the Veteran has neurological impairment associated with any other peripheral nerves that have not already been service-connected. Therefore, a separate or higher rating under a different Diagnostic Code is not warranted. The evidence does not show that it is factually ascertainable that an increase in the severity of peripheral neuropathy of the lower extremities occurred within the one-year lookback period prior to filing the increased rating claim. The VA medical records during this period primarily relate to treatment for other conditions, and do not show that the disabilities increased in severity. (Continued on the next page) In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for ratings in excess of 60 percent for peripheral neuropathy of the right and left lower extremities, and against ratings in excess of 30 percent for peripheral neuropathy (femoral) of the right and left lower extremities. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. L. Wasser, 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.