Citation Nr: 21066518 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 17-35 307 DATE: November 1, 2021 ORDER An evaluation in excess of 30 percent for a right total knee replacement is denied. A separate 10 percent evaluation for right knee instability is granted. Service connection for lumbosacral degenerative disc disease and spondylosis is granted. Service connection for right lower extremity radiculopathy of the femoral nerve is granted. Service connection for right lower extremity radiculopathy of the sciatic nerve is granted. Service connection for left lower extremity radiculopathy of the femoral nerve is granted. Service connection for left lower extremity radiculopathy of the sciatic nerve is granted. REMANDED Entitlement to a total disability rating based upon individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's right total knee replacement manifests as no more than the minimum compensable rating. Severe painful motion and weakness are not present. 2. The Veteran's right knee disability manifests as slight instability. 3. Lumbosacral degenerative disc disease and spondylosis status post fusion surgery is due to the Veteran's service-connected right knee disability. 4. Radiculopathy of the femoral and sciatic nerves, bilaterally, is due to the lumbosacral degenerative disc disease and spondylosis status post fusion surgery. This is the cause of the Veteran's bilateral hip symptoms. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 30 percent for a right total knee replacement have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055. 2. The criteria for a separate 10 percent evaluation of right knee instability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 3. The criteria for service connection for lumbosacral degenerative disc disease and spondylosis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for service connection for right lower extremity radiculopathy of the femoral nerve have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 5. The criteria for service connection for right lower extremity radiculopathy of the sciatic nerve have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 6. The criteria for service connection for left lower extremity radiculopathy of the femoral nerve have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 7. The criteria for service connection for left lower extremity radiculopathy of the sciatic nerve have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1985 to March 1989. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Neither the Veteran nor his attorney have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. An evaluation in excess of 30 percent for a right total knee replacement, including a separate evaluation of right knee instability. The Veteran contends that he is entitled to a higher rating for his right knee total knee replacement because his pain has and functional loss have been severe and he has experienced instability, warranting a separate evaluation. The Veteran's right knee disability is rated as 30 percent disabling under Diagnostic Code 5055, for knee replacement (prosthesis). During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select Diagnostic Codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g); see also Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Prior to the regulatory change, Diagnostic Code 5055 provides a 30 percent rating as the minimum possible rating assignable. A 60 percent rating is warranted for a total knee replacement with chronic residuals consisting of severe painful motion or weakness in the affected extremity. A 100 percent rating is warranted for the one year following implantation of the prosthesis. Intermediate degrees of residual weakness, pain, or limitation of motion (a level of disability in between those contemplated by the 30 and 60 percent ratings) are to be rated by analogy to Diagnostic Codes 5256, 5261, or 5262. 38 C.F.R. § 4.71a, Diagnostic Code 5055. As of February 7, 2021, under the amended criteria, Diagnostic Code 5055 provides that for four months following resurfacing or replacement (prosthesis), the knee joint warrants an evaluation of 100 percent. Thereafter, where there are chronic residuals consisting of severe painful motion or weakness in the affected extremity, a 60 percent rating is warranted. Where there are intermediate degrees of residual weakness, pain or limitation of motion, the disability is rated by analogy to diagnostic codes 5256, 5261 or 5262. The minimum rating for a total replacement is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (effective February 7, 2021). Note (1) provides that when an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 50515056, an additional rating under § 4.71a may not also be assigned for that joint, unless otherwise directed. In this case, the regulations effective prior to February 7, 2021, are more favorable to the Veteran because they do not prohibit a separate evaluation for instability. The only other difference is in the length of time for the 100 percent evaluation. The length of time for the 100 percent evaluation is not an issue in this case. The Veteran's knee replacement was performed in March 2012. The Veteran's claim for an increase was filed in April 2014. The one-year period following the knee replacement had expired by that time. Accordingly, the Board will review the claim under the prior regulations. On this record, a November 2014 VA examination showed the Veteran reporting having 24-hour pain, being limited to standing or walking for short periods of time; moving to desk work due to the inability to perform previous work; being limited to very little reaching and leaning due back pain, hip, and leg pain; and having weakness, giving out, and falling down. Range of motion testing showed right knee flexion was limited to 130 degrees, with objective evidence of painful motion beginning at 130 degrees. Extension was full (0 degrees). There was no objective evidence of painful motion. There was less movement than normal, excess fatiguability and/or, pain on movement, swelling, disturbance of locomotion, and interference with sitting, standing or weight bearing. The examiner estimated additional loss of range of motion (ROM) during flare-ups was 10 degrees of flexion. Muscle strength was normal upon testing. Joint stability tests showed no instability. The Veteran was reported to have a meniscal condition, and has had or had at the time of the examination frequent episodes of joint pain and effusion. The right knee total knee replacement in March 2012 was noted. No assistive devices were used. The examiner found a scar was present, but it was not painful and/or unstable, and the total area was not greater than 39 sq. cm (6 square inches). The length and width of the scar is 17.0 cm by 0.75 cm. This equates to 12.75 sq. cm. A May 2019 VA examination shows the Veteran reporting the right knee swelling every day. He reported dull, aching right knee pain every day. According to the Veteran, due to swelling, the knee feels stiff and tight, and he has reduced ROM. The Veteran reported difficulty standing or walking for long periods of time. He also stated that he was unable to run. He denied having flare-ups. The left knee was also tested, but the joint is damaged, as he had limited left knee ROM. Range of motion tests showed right knee flexion to 115 degrees and extension to 0 degrees. The decreased ROM caused difficulty squatting. Pain was noted on flexion and extension. The examiner estimated ROM during flare-ups and after repeated use over time to be 0 degrees extension to 100 degrees flexion. The examiner specifically stated that passive range of motion was the same as active range of motion. Strength was normal. There was no muscle atrophy or ankylosis. Joint stability test results were normal. The examiner found no current meniscal conditions. The examiner stated that the previous meniscal tear and repair during active service, no longer applicable due to the total knee replacement. The examiner reported that the Veteran did not use assistive devices. The examiner reported the knee scar measured 19 cm by 0.4 cm (7.6 sq. cm), and that it was not painful or unstable. Treatment records show, in June 2013, ROM was 0 to 120 degrees of motion. Strength in quadriceps, hamstrings, tibialis, etc. was normal at 5 out of 5. August 2015 VA treatment record shows the range of motion was painless and full. The Veteran ambulated with a stable gait without assistive devices. The Veteran reported pain of a level 7 out of 10. The Veteran's treatment records show the Veteran frequently reporting a pain level of a 7 to 8 out of 10 level. The reports vary as to the source of the pain. At times, it is his back. At times, it is his knee. At times, it is his hip. For instance, in December 2015, the Veteran reported back pain at an 8/10. In July 2016, he reported back and thigh pain. The Veteran submitted a February 2017 private evaluation of the severity of his right knee disability. The physician reviewed the Veteran's claims file. During the February 2017 private evaluation, the Veteran reported he can walk approximately 30 minutes before his right knee pain and swelling begin to escalate. The Veteran reported having instability and swelling, the source of which is unknown. The evaluation was conducted by telephone. The Veteran provided lay descriptions of the history of his disability and treatment. However, no physical examination was conducted to determine the severity of his right knee disability. His ROM was not measured. His strength and reflexes were not measured. The physician did not have the opportunity to observe the knee in person to determine the extent of any swelling, tenderness, or other observable manifestations. The private physician opined that the Veteran should be given a higher evaluation and that the symptoms are severe in nature and most likely permanent. A higher evaluation for the Veteran's right total knee replacement is not warranted. The evidence does not more nearly approximate the criteria for a higher rating, including chronic residuals consisting of severe painful motion or weakness in the affected extremity. The text and structure of the rating criteria in Diagnostic Code 5055 are clear that the term "severe" is meant to apply to both "weakness" and "painful motion." The structure where "severe" applies to both makes logical sense. The 30 percent criteria state to rate by analogy when there are "intermediate degrees of residual weakness, pain, or limitation of motion," which implies that a lesser degree of weakness would require rating by analogy. To separate "severe" from weakness would negate the terms in the 30 percent criteria. Additionally, separating "severe painful motion" from "or weakness in the affected extremity" would lead to an absurd result because "in the affected extremity" would be separated from "severe painful motion," rendering the text of the regulation entirely unclear. "Severe painful motion, or weakness in the affected extremity" reads as if the severe painful motion does not need to be in the affected extremity. Lastly, the Court has discussed the 60 percent criteria in a way that supports the finding that "severe" applies to "weakness." "As a final matter, the Court notes, without deciding, that the Board may need to explain what it understands 'severe' to mean as it is used to describe painful motion and weakness at the 60 [percent] disability level." Tedesco v. Wilkie, 31 Vet. App. 360, 366 (2019). The evidence is squarely against severe weakness in the extremity. Strength testing is conducted on a scale of 0 to 5, with 5/5 being normal. 4/5 is active movement against some resistance, 3/5 is active movement against gravity, 2/5 is active movement with gravity eliminated, 1/5 is palpable or visible muscle contraction, but no joint movement, and 0/5 is no muscle movement. Although the Veteran reported having weakness at September 2014 and November treatment appointments, and reported weakness and falling down in the November 2014 VA examination, testing of the knee shows normal strength at 5/5. His strength was also normal at 5/5 at an April 2014 private treatment appointment and the examining physician stated there were "[n]o real issues with weakness." At a May 2015 assessment he reported feeling weakness in his in his thigh but after testing it was noted that he had "no weakness of the lower extremity." At an October 2015 private treatment appointment he stated he felt "weak in the knee." In July 2016 his knee extension was "4+/5" bilaterally which is the least severe of all the strength levels after normal. There are four levels that are more severe. It is reasonable to conclude that a strength of "4+" does not describe severe weakness. In a different July 2016 treatment record it was noted that he had "no" lower extremity weakness. His strength was normal at his May 2019 VA examination. In order for weakness to be severe, it should be detectable on testing as worse than a level of "4+." The specific strength tests more credible and probative than the Veteran's assertions of weakness. These specific tests are designed to assess knee strength in a medically sound manner, and to isolate the strength of the knee rather than including other reasons for a feeling of weakness that the Veteran may have had. It is reasonable to conclude that if the weakness was severe, it would be worse than the least severe strength level on testing in an isolated incident and otherwise measured as normal. While the Board recognizes the Veteran feels he has weakness in his physical activity or with standing, his statements are not persuasive in light of the other physical disabilities he has reported, notably back pain and radiculopathy. He has not described the weakness in such a way that would indicate his weakness is due to his chronic residuals of the knee replacement. A July 2016 private medical record noted weakness on neurological examination for his radiculopathy in his lower extremities. In November 2019, he reported weakness in his legs because of nerve damage since his back surgery in 2016, and the provider's assessment was "chronic back pack w/ leg weakness." With regard to painful motion, the Board finds the evidence is against finding that his painful motion is severe. Although "limitation of motion" and "painful motion" are separate concepts, the Board is not precluded from considering limitation of motion in assessing painful motion under Diagnostic Code 5055. Tedesco v. Wilkie, 31 Vet. App. 360 (2019). His range of motion has remained good in comparison to normal ranges of motion (i.e. 0 to 140 degrees). His extension was not limited and he retained nearly three quarters of his flexion. The November 2014 examination reported that objective evidence of painful motion did not begin until 130 degrees of flexion. The onset of pain so far along the range of motion is a strong indicator in the Board's view that painful motion is not severe during the lower end of the ROM. In addition to his limitation of motion, the Veteran's statements themselves reveal that he is able to walk or stand for 30 minutes before his symptoms escalate. At his November 2014 and May 2019 VA examinations, he did not use or wear a assistive device such as a brace or cane for his pain. Although his pain caused difficulty walking, standing, and squatting, it did not prevent him from doing these activities. In May 2019, the examiner noted that the Veteran had difficulty standing or walking "for long periods of time," indicating that he was able to do these activities to a lesser extent. The only activity precluded was running. The record does not show that his pain level has caused actual harm to him or prevented him from engaging in any activities other than running. In summary, he has painful motion that does not rise to the level of "severe." The private medical evaluation by Dr. D.M., submitted in support of the claim is not deemed probative by the Board because the Dr. Dr. D.M. did not physically examine the Veteran. He did not conduct tests to observe the Veteran's pain on motion or his weakness before rendering a conclusion that the Veteran's symptoms are severe. He also includes instability in his assessment, whereas, the instability is separately rated hereunder. Further, he includes an assessment of the knee prior to the period on appeal when the knee replacement had not been performed. Additionally, the private evaluation does not persuasively explain why painful motion is severe. Conclusions as to strength are contradicted by the physical examination and testing of the knee. Accordingly, the conclusion as to the severity of painful motion and the severity of the total knee replacement residuals is undermined. With regard to intermediate degrees of residual weakness, pain or limitation of motion, rating by analogy to Diagnostic Codes (DCs) 5256, 5261, or 5262 do not result in a more favorable evaluation than 30 percent. DC 5256 applies to ankylosis of the knee, which the Veteran does not have Nor does he have the functional equivalent of ankylosis. His extension is normal and at worst, his flexion does not meet even the level of severity to meet a compensable rating. DC 5262 applies to impairment of the tibia and fibula, which the Veteran does not have. To warrant a 40 percent rating, the disability would need to approximate nonunion of the tibia and fibula with loose motion, that requires a brace. Even rating by analogy, the Veteran does not use a brace, and the evidence does not show, nor does he assert, that one is required. Thus, he does not meet the criteria for a higher evaluation than his current 30 percent. DC 5261 applies to limitation of extension. The Veteran's extension has been full on all tests, which corresponds to a noncompensable evaluation. Even when considering functional loss, he has not described symptoms that would be analogous to functional limitation of extension to 30 degrees, which would be necessary for a higher rating under DC 5261 as compared to his current rating. This is contrary to the probative medical evidence which shows that even during a flare-up and after repeated use over time, his extension is still estimated to be full (i.e. 0 degrees). The Veteran's representative asserts that the evidence shows the functional loss of the Veteran's knee is severe. See August 2020 correspondence. In support of the Veteran's claim, his representative cites medical records from July 2011 and December 2011 showing factors of functional loss. The Board notes that these records are prior to the appeal period, and more importantly, prior to the total knee replacement surgery. Therefore, they have little probative value. The Veteran's representative further cites a November 2014 VA examination report showing swelling, limping, fatigability, that pose limitations with standing walking and sitting. A May 2015 record showed chronic pain, swelling, weakness, and instability. A partial October 2015 record from Pinnacle Orthopedics supplied by the Veteran reports that swelling, pain, weakness, and instability all worsen with physical activity. Swelling and other factors of functional loss are contemplated by range of motion under DC 5261. The DC does not permit evaluation by analogy to DC 5260. As noted above, an evaluation for other intermediate degrees of residual weakness, pain or limitation of motion does not result in an evaluation more favorable to the Veteran than his currently awarded 30 percent. The Veteran, through his representative, cites Lyles v. Shulkin, 29 Vet. App. 107 (2017), for the proposition that evaluators may use 38 C.F.R. §§ 4.40, 4.45, and 4.59, to potentially craft a higher musculoskeletal evaluation than would otherwise be supported by mechanical application of a given DC for limitation of motion. The representative argues that a higher evaluation can be crafted based on weakened movement, excess fatigability, incoordination, and pain on movement. The factors set forth in 38 C.F.R. §§ 4.40, 4.45 do not contain rating criteria, and are there to provide guidance to understand the nature of the Veteran's disability, after which a rating is determined based on the 38 C.F.R. §4.71a criteria. Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016). Both 38 C.F.R. §§ 4.40 and 4.45 identify causes and manifestations of functional loss. The Veteran's representative states that the Veteran's locomotion disturbance, sitting and standing interference, and excess fatigability are all forms of functional loss. These are possible manifestations of functional loss as set forth in 38 C.F.R. §§ 4.40 and 4.45. However, the regulations show that VA has chosen to measure and then rate functional loss using specific criteria. Disability may occur when the Veteran cannot perform normal working movements of the body with normal excursion, strength, speed, coordination, and endurance, but then the disability is rated based upon the criteria set forth in 38 C.F.R. § 4.71a. Id. at 785. Lyles is about potentially overlapping symptomology in the rating criteria for limitation of motion of the knee, instability of the knee, and meniscal conditions, given that the same manifestations may not be compensated twice under the rating schedule. 29 Vet. App. at 109. In Lyles, the Court explained that when assigning a rating under Diagnostic Code 5261, a rating can be "elevated" to a higher rating under 38 C.F.R. §§ 4.40, 4.45, and 4.59. But this would be due to additional functional loss with use or during flare ups, which should be portrayed in terms of range of motion lost. Id. at 118. Extension during flare ups was described in terms of degrees of motion lost and it remained normal. Flexion decreased to 100 degrees during a flare up. Causes of functional loss such as locomotion disturbance, sitting and standing interference, and excess fatigability may produce functional loss that is measurable under the rating criteria. But, ultimately a rating is assigned using the criteria in 38 C.F.R. § 4.71a, and the criteria for a higher rating are not met. When considering his functional loss, his extension is not compensable, he does not have severe painful motion, severe weakness, or a disability that causes him to need to require a brace. It does not cause ankylosis or the functional equivalent of ankylosis. For the foregoing reasons, the Board finds an evaluation higher than 30 percent for right total knee replacement under DC 5055 (both prior to and beginning February 7, 2021) is warranted. The Board has also considered whether separate evaluations under other Diagnostic Codes apply. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Under Tedesco v. Wilkie, 31 Vet. App. 360 (2019), a separate evaluation under instability is permitted when assigning evaluations under DC 5055. Under the version of DC 5055 effective February 7, 2021, a separate evaluation is not permitted. See Note (1) to the current version of DC 5055 provides that when an evaluation is assigned for joint resurfacing or the prosthetic replacement of a joint under diagnostic codes 50515056, an additional rating under § 4.71a may not also be assigned for that joint, unless otherwise directed. As the prior version of DC 5055 is more favorable to the Veteran for this reason, it will be used. Under the prior regulations, Diagnostic Code 5257, for other impairment of the knee, provides a 10 percent rating for slight recurrent subluxation or lateral instability. A 20 percent rating is warranted for moderate recurrent subluxation or lateral instability. A 30 percent rating is warranted for severe recurrent subluxation or lateral instability. 38 C.F.R. § 4.71a, Diagnostic Code 5257. According to MERRIAM WEBSTER'S COLLEGIATE DICTIONARY 999 (11th Ed. 2007), "slight" means small in amount. "Moderate" means limited in scope or effect. "Severe" means very painful or harmful or of a great degree. Objective medical evidence is not required to establish lateral knee instability under Diagnostic Code 5257, so objective medical evidence cannot be categorically found more probative than lay evidence with respect to this Diagnostic Code. See English v. Wilkie, 30 Vet. App. 347, 352-53 (2018). On this record, an August 5, 2013, private treatment record shows the knee had mild laxity, but was grossly stable. August 2015 VA treatment record shows some flexion instability, described as 4 degrees of varus-valgus give at 90 degrees of flexion. December 2015 private treatment records also show instability of the knee. Giving the Veteran the benefit of the doubt, the Board finds that a separate evaluation for slight instability is warranted. The reports indicating the presence of laxity or instability describe it as mild or only at one particular degree of motion in the ROM. Therefore, the Board finds it more nearly approximates the slight instability. The Board has also considered whether DC 5258 or 5259 pertaining to conditions of the meniscus apply. The Board finds this would be improperly considering the same symptoms or functional impairment. Lyles, 29 Vet. App. 107. In that regard, the May 2019 VA examiner reported that the previous meniscal tear and repair during active service are no longer applicable due to the total knee replacement. The Board finds this is persuasive evidence that symptomatology due to previous meniscus injury is now contemplated by the total knee replacement, because it appears that the total knee replacement, as the name suggests, replaces the knee joint, including the need for a meniscus. Dr. D. M. went into a lengthy discussion about the effects of a partial meniscectomy. However, the Veteran's total knee replacement was performed prior to the period on appeal, and thus, mooted the issue regarding the Veteran's meniscectomy. As part of the request for a higher evaluation of the total knee replacement, the Board considers the evaluation of the scar associated with the total knee replacement. The Veteran's knee replacement scar is currently evaluated noncompensably under DC 7801. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after August 13, 2018. Claims pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, Diagnostic Code 7801, was for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are deep and nonlinear. Under these criteria, a scar with an area or areas of at least 6 square inches (39 sq. cm.) but less than 12 square inches (77 sq. cm.) warrants a 10 percent rating. A scar with an area or areas of at least 12 square inches (77 sq. cm.) but less than 72 square inches (465 sq. cm.) warrants a 20 percent rating. A scar with an area or areas of at least 72 square inches (465 sq. cm.) but less than 144 square inches (929 sq. cm.) warrants a 30 percent rating. A scar with an area or areas of 144 square inches (929 sq. cm.) or greater warrants a 40 percent rating. 38 C.F.R. § 4.118. Prior to August 13, 2018, Note 1 to Diagnostic Code 7801 instructed that a deep scar is one associated with underlying soft tissue damage. Id. [Include any other relevant Note(s) to Diagnostic Code 7801.] Since August 13, 2018, Diagnostic Code 7801 is for burn scar(s) or scar(s) due to other causes, not of the head, face, or neck, that are associated with underlying soft tissue damage. 38 C.F.R. § 4.118. Diagnostic code 7801 was otherwise unchanged by the August 13, 2018, amendments. The Board finds that the preponderance of the evidence is against the assignment of a compensable rating under Diagnostic Code 7801 because the Veteran's scar covers an area less than 6 square inches (39 sq. cm.). As described above, the VA examiners in November 2014 and May 2019 found the scar to be 12.75 sq. cm. and 7.6 sq. cm., respectively. The May 2019 VA examiner found the scar was associated with soft tissue damage. The examiners found the scars were not painful or unstable. The Board has also considered the other Diagnostic Codes pertaining to scars. However, the Veteran's scar is not of the head, face, or neck. Although it is superficial and not associated with underlying soft tissue damage, it does do not cover an area or areas of 144 square inches or greater. Moreover, the Veteran's scar is not unstable or painful. Therefore, Diagnostic Codes 7800, 7802, and 7804, both prior to and from August 13, 2018, are inapplicable. Finally, the evidence of record shows there are no other disabling effect(s) not considered in a rating provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805. Service Connection 1.Service connection for lumbosacral degenerative disc disease and spondylosis. The Veteran asserts that his lumbar degenerative disc disease and spondylosis are secondary to his right knee disability. The Veteran asserts that the chronic limp from the right knee disability caused the Veteran's lumbar spine disability. Private evaluator Dr. M. opined in February 2017 evaluation report that the Veteran's chronic limp resulted in an unbalanced gait. This in turn resulted in Chronic Mechanical Low Back syndrome that resulting in the Veteran needing a two staged lumbar surgery. The evaluator described in general terms what Mechanical Low Back Syndrome is and cited a medical article showing that a change in biomechanical stresses across the lumbar joint can stem from an antalgic gait. The evaluator did not apply this article to the Veteran's case, other than the general statement that the Veteran's antalgic gait caused the Mechanical Low Back Syndrome. The evaluator's discussion of other Veteran's is unpersuasive, however, because facts differ in each case. On the other hand, the May 2019 VA examiner opined that, although an altered gait from a severe right knee condition can cause back pain, particularly muscular back pain, the examiner found the that the severe spinal degeneration the veteran has had that required him to have a spinal fusion cannot be explained alone due to an altered gait from right knee pain. The examiner pointed to the Veteran's work as an aircraft mechanic for almost 20 years in support of this claim. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current degenerative disc disease with spondylosis is proximately due to his service-connected right knee disability. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for degenerative disc disease with spondylosis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for a right hip disability. 3. Service connection for a left hip disability. The May 2019 VA examiner found that the Veteran's bilateral hip symptoms are due to radiculopathy from the Veteran's spinal degeneration and spondylosis. Accordingly, service connection for bilateral right lower extremity radiculopathy of the femoral nerve and radiculopathy of the sciatic nerve, as shown by the May 2019 VA examination, is warranted. REASONS FOR REMAND 1. Entitlement to a total disability rating based upon individual unemployability is remanded. A Supplemental Statement of the Case (SSOC) was not issued on the issue of a total disability rating based on individual unemployability following the February 2019 Board remand. The RO did attempt to obtain an update to the Veteran's employment history, however, the Veteran did not respond to VA's request. On remand, VA should make another attempt to obtain the Veteran's occupational history and any accommodations made to him in any employment. The matters are REMANDED for the following action: (Continued on the next page) 1. Ask the Veteran to complete a TDIU claim form and to describe any accommodations made to him in any employment, in particular his most recent employment. 2. If upon completion of the above action any benefit sought on appeal remains denied, a Supplemental Statement of the Case should be issued, and the case should be returned to the Board after compliance with appellate procedure. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Rocktashel, 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.