Citation Nr: 21066902 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 18-37 708 DATE: November 2, 2021 ORDER Entitlement to an increased rating for mechanical back syndrome, rated as 10 percent prior to May 18, 2018, and 40 percent, thereafter, is denied. Entitlement to an increased rating higher than 10 percent for cervical arthritis prior to July 12, 2021, is denied. Entitlement to an increased rating of 30 percent, but no higher, for cervical spine arthritis, is granted, effective July 12, 2021, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating higher than 10 percent for painful motion of the right knee prior to July 12, 2021, is denied. Entitlement to an increased rating of 20 percent, but no higher, for limitation of flexion of the right knee, effective July 12, 2021, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 20 percent, but no higher, for limitation of extension of the right knee, effective July 12, 2021, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a separate rating of 10 percent, but no higher, effective May 28, 2014, and 20 percent, but no higher, effective July 12, 2021, for lateral instability of the right knee is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating higher than 10 percent for painful motion of the left knee prior to July 12, 2021, is denied. Entitlement to an increased rating of 20 percent, but no higher, for limitation of flexion of the left knee, effective July 12, 2021, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to an increased rating of 20 percent, but no higher, for limitation of extension of the left knee, effective July 12, 2021, is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to a separate rating of 10 percent, but no higher, effective May 28, 2014, and 20 percent, but no higher, effective July 12, 2021, for lateral instability of the left knee is granted, subject to the laws and regulations governing the payment of monetary benefits. Entitlement to service connection for bilateral carpal tunnel syndrome with hand swelling is granted. Entitlement to service connection for bilateral plantar fasciitis with bone spurs is granted. New and material evidence has been received to reopen entitlement to service connection for bilateral hearing loss, and to this extent only, the claim is granted. REMANDED Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. Entitlement to special monthly compensation (SMC) based on the need of aid and attendance of another person is remanded. FINDINGS OF FACT 1. The Veteran's lumbar spine disability is manifest by forward flexion most severely limited to 85 degrees prior to May 18, 2018, and most severely limited to 30 degrees of forward flexion, effective May 18, 2018. 2. The Veteran's cervical spine disability is manifested by forward flexion mostly severely limited to 35 degrees of forward flexion, effective prior to July 12, 2021, and most severely limited to 15 degrees of forward flexion, effective July 12, 2021. 3. Effective prior to July 12, 2021, the Veteran's patellofemoral syndrome of the right knee is manifested by painful motion. 4. Effective July 12, 2021, the Veteran's patellofemoral syndrome of the right knee is manifested by flexion limited to 30 degrees; and extension limited to 15 degrees. 5. Effective May 28, 2014, the Veteran's patellofemoral syndrome of the right knee is manifested by slight lateral instability. 6. Effective July 12, 2021, the Veteran's patellofemoral syndrome of the right knee is manifested by moderate lateral instability; and is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace. 7. Effective prior to July 12, 2021, the Veteran's patellofemoral syndrome of the left knee is manifested by painful motion; and effective in November 2019 by compensable limitation of extension only at 10 degrees. 8. Effective July 12, 2021, the Veteran's patellofemoral syndrome of the left knee is manifested by flexion limited to 30 degrees; and extension limited to 15 degrees. 9. Effective May 28, 2014, the Veteran's patellofemoral syndrome of the left knee is manifested by slight lateral instability. 10. Effective July 12, 2021, the Veteran's patellofemoral syndrome of the left knee is manifested by moderate lateral instability; and is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace. 11. The Veteran's bilateral carpal tunnel syndrome with hand swelling is related to his duties as an aviation structural mechanic in service. 12. The Veteran's bilateral plantar fasciitis with bones spurs is related to in-service injuries. 13. The Veteran's service connection claim for bilateral hearing loss was denied in an August 2011 rating decision. The Veteran did not timely appeal this decision; nor has he asserted clear and unmistakable error in this decision. 14. The evidence received since the August 2011 rating decision is not duplicative or cumulative of evidence previously of record and raises a reasonable possibility of substantiating the service connection claim for bilateral hearing loss. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for mechanical back syndrome are not met, prior to May 18, 2018, nor higher than 40 percent, thereafter. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5237. 2. The criteria for a rating in excess of 10 percent for a cervical spine disability are not met, effective prior to July 12, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237-5242. 3. The criteria for a rating of 30 percent, but no higher, for a cervical spine disability are met, effective July 12, 2021. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5237-5242. 4. Effective prior to July 12, 2021, the criteria for a rating in excess of 10 percent for patellofemoral syndrome of the right knee with scars are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5010. 5. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for limitation of flexion due to patellofemoral syndrome of the right knee with scars are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 6. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for limitation of extension due to patellofemoral syndrome of the right knee with scars are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 7. Effective May 28, 2014, the criteria for a rating of 10 percent, but no higher, for lateral instability of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 8. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for lateral instability of the right knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 9. Effective prior to July 12, 201, the criteria for a rating in excess of 10 percent for patellofemoral syndrome of the left knee with scars are not. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5010, 5261. 10. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for limitation of flexion due to patellofemoral syndrome of the left knee with scars are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 11. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for limitation of extension due to patellofemoral syndrome of the left knee with scars are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5261. 12. Effective May 28, 2014, the criteria for a rating of 10 percent, but no higher, for lateral instability of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 13. Effective July 12, 2021, the criteria for a rating of 20 percent, but no higher, for lateral instability of the left knee are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257. 14. The criteria for service connection for bilateral carpal tunnel syndrome with hand swelling are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 15. The criteria for service connection for bilateral plantar fasciitis with bone spurs are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 16. The August 2011 rating decision denying service connection for bilateral hearing loss is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 3.156(c), 20.1103. 17. Since the August 2011 rating decision, new and material evidence has been received with respect to the Veteran's claim of entitlement to service connection for bilateral hearing loss; and the claim is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from June 1983 to June 2003. This matter comes to the Board of Veterans' Appeals (Board) from a November 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a Board virtual hearing in June 2021 before the undersigned Veterans Law Judge. Given that the hand swelling has been found to be a symptom of the carpal tunnel syndrome, and bone spurs appear to be a symptom of plantar fasciitis in this case, the Board has combined the issues of entitlement to service connection for bilateral carpal tunnel syndrome and hand swelling, as well as service connection for plantar fasciitis and bones spurs, based on the evidence of record. Increased Rating 1. Entitlement to an increased rating for mechanical back syndrome, rated as 10 percent prior to May 18, 2018, and 40 percent, thereafter The Veteran seeks higher ratings for his lumbar spine disability. He testified at the June 2021 Board hearing that he has had flare-ups of back pain for many years, that occur several times per month. See June 2021 Board hearing transcript, pp. 5-6. The Veteran's lumbar spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5237. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis is defined 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. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is "always" considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The Veteran's mechanical back syndrome is presently rated as 10 percent disabling prior to May 18, 2018; and 40 percent disabling, effective May 18, 2018. A November 2014 Disability Benefits Questionnaire (DBQ) notes that the Veteran had mechanical back syndrome that had been diagnosed in the 1980s. He stated that the condition began when he injured his back lifting aircraft tires and that his back had gotten worse. He indicated that he experienced flare-ups when his back would feel sore, stiff, and it was hard to twist. Range of motion in the lumbar spine was from 0 to 85 degrees of forward flexion with no additional loss of motion after repetitive use studies. Functional loss included less movement than normal and pain on movement. He did not have intervertebral disc syndrome. The examiner noted that the Veteran's posture and gait were within normal limits. There were contributing factors of pain, weakness, fatigability and/ or incoordination, but no additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time. There also was no guarding or muscle spasm of the thoracolumbar spine severe enough to result in abnormal gait or abnormal spinal contour. Sensory examination was normal and straight leg raising testing was negative. The Veteran did not have radicular pain or any other signs or symptoms of radiculopathy. A March 2016 VA primary care note shows the Veteran complained of worsening back pain. It was noted that he had degenerative joint disease of the back. A May 2018 VA examination report shows the Veteran had a diagnosis of mechanical back syndrome and degenerative arthritis of the spine. It was noted that his pain had progressed since the last examination. He had a constant, dull, achy, throbbing pain that would become sharp with bending, and twisting. Prolonged sitting also aggravated his back. The pain radiated to his bilateral legs, left greater than right. He had numbness/tingling, and pins and needles. He had flare-ups that occurred with increased physical activity, which also would awaken the Veteran from sleeping. During flare-ups the Veteran had to rest and did not engage in physical activity. Functional loss included being unable to climb, bend, or lift. Range of motion studies showed forward flexion to 30 degrees, which affected his lifting and bending. There was pain on all ranges of motion. There also was evidence of pain with weight-bearing. The Veteran was not able to perform repetitive use testing due to increase in pain. There was no ankylosis. The Veteran had intervertebral disc syndrome but had not had any episodes of acute signs and symptoms that required bedrest prescribed by a physician in the past 12 months. The Veteran used a cane when his back pain was severe. Passive range of motion of the thoracolumbar spine could not be adequately performed without resulting in possible injury. The examiner also noted that the Veteran's degenerative arthritis of the spine was a progression of his service-connected mechanical back syndrome. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the lumbar spine disability prior to May 18, 2018, and higher than 40 percent, thereafter. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the Veteran's statements that he had flare-ups of back pain for many years, that occur several times per month would not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or the combined range of motion of the thoracolumbar spine not greater than 120 degrees prior to May 18, 2018. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis prior to May 18, 2018. Also, effective May 18, 2018, the degree of additional limitation reflected by the statements regarding flare-ups would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Of note, effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign Diagnostic Code 5242 for all other disc diagnoses." However, given that the Veteran's impairment does not meet the criteria for a higher rating for his lumbar spine under Diagnostic Code 5243, the revisions specifying what constitutes IVDS are not applicable. Regarding neurological impairment, the Veteran has already been granted service connection for radiculopathy of the bilateral lower extremities and the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the lumbar spine disability prior to May 18, 2018, and in excess of 40 percent, thereafter. 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. 2. Entitlement to an increased rating higher than 10 percent for cervical arthritis The Veteran contends that he is entitled to a higher rating for his cervical spine disability. He testified at the Board hearing that his neck hurt the most in the morning and it took several hours to get enough rotation to look side to side. See June 2021 Board hearing transcript, p. 7. The Veteran's cervical spine disability is rated under 38 C.F.R. § 4.71a, Diagnostic Codes 5242-5237 (degenerative arthritis of the spine-cervical strain). Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or the combined range of motion of the cervical spine not greater than 170 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is warranted for forward flexion of the cervical spine to 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is warranted for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Unfavorable ankylosis and favorable ankylosis are defined as outlined above." Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion including of the cervical spine, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are for consideration, as outlined above. See also DeLuca, Mitchell, Thompson, Burton, Correia, and Sharp, all supra. On a November 2014 Disability Benefits Questionnaire (DBQ) the Veteran stated that he did not have full range of motion of the cervical spine and that pain would go down his back and make his "eyes feel different" when he turned his head. Flare-ups impacted the function of his ability to turn his head due to pain. Range of motion studies showed forward flexion to 40 degrees with painful motion beginning at that point. The range of motion remained unchanged after repetitive use testing. Functional impairment included less movement than normal and weakened movement. The Veteran had guarding or muscle spasm present, but it did not result in abnormal gait or spinal contour. There was no radicular pain or any other signs or symptoms due to radiculopathy. There also were no other neurologic abnormalities related to the cervical spine. In addition, there was no intervertebral disc syndrome (IVDS). The Veteran's posture and gait were within normal limits. There were contributing factors of pain, weakness, fatigability and/ or incoordination but no additional limitation of functional ability of the cervical spine during flare-ups or repeated use over time. A February 2015 VA treatment record notes that the Veteran had a clinical history of cervicalgia with bilateral upper extremity radiculopathy and visual changes with neck movement. The magnetic resonance imaging (MRI) report showed multilevel degenerative disc disease causing the most pronounced neuroforaminal narrowing within the upper cervical spine. X-ray examination showed mild degenerative changes. There also was moderate right foraminal narrowing at C3-C4. A March 2015 VA treatment record shows the Veteran had a complaint of cervical radiculopathy, chronic for years, with intermittent numbness in the bilateral hands. In April 2015 a private treatment record shows the Veteran had a 15-year history of neck pain extending into the bilateral upper extremities into the shoulders. After examination the Veteran, the clinician noted that it was not really clear whether the Veteran's symptoms were related to shoulder pathology or neck pathology. A July 2015 private treatment record notes the Veteran was seen for neck pain radiating into the bilateral shoulders, right greater than left. He appeared to have mechanical shoulder pain. The clinician reviewed the Veteran's cervical spine MRI report and noted that it revealed multiple levels of degenerative disc disease causing the most pronounced neuroforaminal narrowing within the upper cervical spine. On physical examination, sensation was intact to light touch throughout. Motor examination revealed 4+ out of 5 strength throughout the bilateral upper extremities. There was a positive impingement sign in the shoulders bilaterally. A July 2016 private treatment record shows the Veteran had mild right median neuropathy at the carpal tunnel but there were no signs of a right cervical radiculopathy, brachial plexopathy or other focal neuropathy. A November 2017 DBQ shows the Veteran reported limited right and left lateral rotation of his neck. He also stated that he would get tunnel vision and felt like something was pushing on his right eye if he moved his neck too far to the right. He did not report any flare-ups or functional impairment due to his cervical spine disability. Range of motion studies showed forward flexion to 40 degrees. There was no additional loss of motion after repetitive use studies. The examiner noted that the range of motion was normal for body habitus and age and had no clinical significance. However, the examiner also noted that range of motion contributed to functional loss in the form of pain with movement and decreased movement. The examiner indicated that pain was noted on examination, but it did not result in or cause functional loss. There was no localized tenderness or pain on palpation of the joint or associated soft tissue of the cervical spine. There also was no evidence of pain with weight-bearing. Factors that caused functional loss included pain, weakness, and lack of endurance. There was no radicular pain or any signs or symptoms due to radiculopathy. There also was no IVDS of the cervical spine. The examiner commented that passive range of motion of the spine was not performed as it was not feasible to do this in a safe and reasonable manner. Non-weight bearing assessment was not applicable. There was no objective evidence of pain when the spine was in non-weight-bearing position at rest. A peripheral nerves DBQ also was performed in November 2017 which showed a diagnosis of carpal tunnel syndrome. Examination of the upper radicular group (5th and 6th cervicals), middle radicular group, and lower radicular group was normal. A July 2021 DBQ submitted by the Veteran shows the Veteran stated that he was unable to turn his head/neck side to side or up and down. He also was unable to work as he needed to be able to lay down and take pressure off of his neck and spine that occurred three to four times per month and could last the whole day or even into the next day. Range of motion studies showed forward flexion of the cervical spine to 15 degrees. There was no additional motion loss after repetitive use studies. Passive range of motion was the same as active range of motion. There was pain on weight-bearing, active motion, and passive motion. The cervical spine had tenderness to palpation throughout the examination. The Veteran also had muscle spasm and guarding resulting in abnormal gait or spinal contour. Additional factors contributing to his disability included interference with sitting and standing, less movement than normal, and weakened movement. Sensory examination showed decreased sensation to light touch at the shoulder area (C5), inner/outer forearm (C6-T1), and hand/fingers (C6-8). The examiner noted that the Veteran had radicular pain or any other symptoms due to radiculopathy. There was moderate constant pain, intermittent pain, paresthesias and/ or dysesthesias, and numbness in the bilateral upper extremities. The nerves involved included the C5-C6 nerve roots (upper radicular group), C7 nerve root (middle radicular group), and C8-T1 nerve roots (lower radicular group). There was no ankylosis of the spine or IVDS. Of note, a peripheral nerve DBQ filled out by the same physician as the cervical spine DBQ in July 2021 shows normal examination of the upper radicular group, middle radicular group, and lower radicular group. The Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the cervical spine disability prior to July 12, 2021. However, effective July 12, 2021, the medical evidence more closely approximates the criteria for a 30 percent rating based on the findings of forward flexion to 15 degrees and pain on any movement, which is akin to favorable ankylosis of the cervical spine. The functional equivalent of ankylosis during flare-ups, pursuant to 38 C.F.R. § 4.40 and 4.45, can satisfy the criteria for a rating based on ankylosis. Chavis v. McDonough, __ Vet. App. __, No. 18-2928, 2021 U.S. App. Vet. Claims LEXIS 660 (Apr. 16, 2021). The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain during flare-ups. However, even considering the Veteran's lay reports of symptoms and noted functional loss, prior to July 12, 2021, the degree of additional limitation reflected by the statements of painful movement would not result in limitation of motion more nearly approximating forward flexion of 15 degrees but not greater than 30 degrees or the combined range of motion of the cervical spine not greater than 170 degrees. Additionally, the Veteran did not have muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. Effective July 12, 2021, the medical evidence shows the criteria for a 30 percent rating for the cervical spine disability are warranted based on the findings of forward flexion to 15 degrees and pain on any movement. A rating in excess of 30 percent is not warranted as even when considering the functional limitation during a flare-up, the Veteran's symptoms do not more nearly approximate the cervical spine fixed in flexion or extension and one of the additional symptoms set forth in Note 5. Consideration has also been given to assigning a rating under the Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes. However, the Veteran does not have IVDS of the cervical spine. See 38 C.F.R. § 4.71a, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. Regarding neurological impairment, the lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. The Veteran complained that his neck pain radiated into his upper extremities and that his vision was affected when he turned his neck. See, e.g., March 2015 VA treatment record noting the Veteran's complaints of cervical radiculopathy, chronic for years, with intermittent numbness in the bilateral hands; and November 2017 DBQ noting the Veteran's reports that he would get tunnel vision and felt like something was pushing on his right eye if he moved his neck too far to the right. In April 2015 a private treatment record shows the Veteran had a 15-year history of neck pain extending into the bilateral upper extremities into the shoulders; but the clinician commented that it was not clear whether the Veteran's symptoms were related to shoulder pathology or neck pathology. Subsequent (probative) examination of the nerves affected by the cervical spine was normal. The July 2021 DBQ submitted by the Veteran noted that the Veteran's cervical spine involved radiculopathy in the upper, middle, and lower radicular groups. However, the same physician filled out a peripheral nerve DBQ and noted normal neurological findings in the upper, middle, and lower radicular groups, which is consistent with the other evidence of record, and undermines the probative value of the neurological findings on the cervical spine report. The Veteran also has carpal tunnel syndrome of the bilateral hands, which, as noted below, is granted in this decision. While the Veteran has been evaluated multiple times for his complaints, there are no probative medical findings showing any neurological impairment related to the Veteran's cervical spine. Even though the Veteran is competent to state that he experiences pain and numbness in his upper extremities, and that his vision changes with turning his neck, he is not competent to attribute these symptoms to his cervical spine disability. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Instead, such a determination must be made by a medical professional with appropriate expertise. Id. Accordingly, the Veteran's statements of neurological impairment related to his cervical spine disability are not competent evidence. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the cervical spine disability prior to July 12, 2021. Effective July 12, 2021, a rating of 30 percent, but no higher, is warranted for the cervical spine disability. In denying any higher 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. Entitlement to increased ratings for right and left knee patellofemoral syndrome with scars The Veteran seeks higher ratings for his right and left knee disabilities. At the June 2021 Board hearing, the Veteran testified that he had buckling and falling with instability in the knees. See June 2021 Board hearing transcript, p.18. He also testified that he could not fully extend or flex his knees. Id. at 16. The Veteran's patellofemoral syndrome of the right and left knees with scars is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260, for limitation of flexion. Effective May 28, 2014, he has separate 0 percent ratings for right and left knee limited extension, under 38 C.F.R. § 4.71a, Diagnostic Code 5261. The assigned Diagnostic Code 5260 indicates that the bilateral knee patellofemoral syndrome is rated based on compensable limitation of flexion. 38 C.F.R. § 4.71a. A review of the evidence reflects that prior to July 12, 2021, the bilateral knee patellofemoral syndrome has been rated based on painful noncompensable limitation of motion. The left knee patellofemoral syndrome had compensable limitation of extension noted in November 2019, which warranted a single 10 percent rating, but not compensable limitation of flexion prior to July 2021. The right knee patellofemoral syndrome was not manifested by compensable limitation of motion (i.e., limitation of flexion or extension) at any time prior to the most recent Disability Benefits Questionnaire submitted by the Veteran in July 2021. Therefore, prior to July 12, 2021, the Diagnostic Code assigned should have been only Diagnostic Code 5010, to show that the patellofemoral syndrome of the right knee is being rated based on noncompensable limitation of motion that is painful. 38 C.F.R. § 4.71a. The left knee patellofemoral syndrome can be rated under Diagnostic Code 5261 as of November 2019, because limitation of extension was noted to be 10 degrees, which warrants a 10 percent rating under Diagnostic Code 5261. However, the Veteran would not receive a separate rating for limitation of flexion, as discussed in more detail below, because his flexion was not limited to a compensable degree as of November 2019. Thus, the rating for the left knee patellofemoral syndrome would remain 10 percent prior to July 12, 2021, regardless if he was rated under Diagnostic Code 5261 or Diagnostic Code 5010. Diagnostic Code 5010 provided that arthritis due to trauma, substantiated by x-ray findings is to be rated as degenerative arthritis. Under 38 C.F.R. § 4.71a, Diagnostic Code 5003, degenerative arthritis is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. If noncompensable limitation of motion is demonstrated, a 10 percent rating is assigned for each major joint or group of minor joints affected. In the absence of any limitation of motion, a 10 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups, and a 20 percent rating is warranted for involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. 38 C.F.R. § 4.71a, Diagnostic Code 5003. For the purpose of rating disability from arthritis, the knees are considered major joints. 38 C.F.R. § 4.45 (f). The Board notes that 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. 76453 (Nov. 30, 2020). Prior to February 7, 2021, the Board will consider the former version of the diagnostic codes only; however, for the period beginning February 7, 2021 the Board will consider both the old and amended version (amended code) of the diagnostic code and rate based on whichever is most favorable to the claimant. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Degenerative arthritis established by x-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. The amendment to Diagnostic Code 5010, effective February 7, 2021, for post-traumatic arthritis was clarified that it can be rated as limitation of motion, dislocation, or instability. 38 C.F.R. § 4.71a, 85 Fed. Reg. 76453 (Nov. 30, 2020). Under the amendment, Diagnostic Code 5002 also was renamed from rheumatoid arthritis to multi-joint arthritis to take into account all systemic arthritis (except post-traumatic and gout). Id. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is assigned for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Under Diagnostic Code 5261, a noncompensable rating is warranted for extension limited to 5 degrees. A 10 percent rating is warranted for extension limited to 10 degrees. A 20 percent rating is warranted for extension limited to 15 degrees. A 30 percent rating is warranted for extension limited to 20 degrees. A 40 percent rating is warranted for extension limited to 30 degrees. A 50 percent rating is warranted for extension limited to 45 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5261. When evaluating musculoskeletal disabilities based on limitation of motion including of the knees, the provisions of 38 C.F.R. § 4.40 and 38 C.F.R. § 4.45 are for consideration, as outlined above. See also DeLuca, Mitchell, Thompson, Burton, Correia, and Sharp, all supra. In evaluating the medical evidence of record, the Veteran's patellofemoral syndrome of the right and left knees does not warrant a rating higher than 10 percent based on limitation of motion prior to July 12, 2021. A November 2014 VA Disability Benefits Questionnaire (DBQ) shows range of motion studies in the knees were from 5 degrees of extension to 135 degrees of flexion. There was no additional motion loss after repetitive use testing. Functional loss and/ or impairment included pain on movement. The report noted that there were contributing factors of pain, weakness, fatigability and/ or incoordination, but no additional limitation of functional ability of the knee joints during flare-ups or repeated use over time. The Veteran's scarring on the knees was measured as 0.8 x 0.2; 1.2 x 0.2; and 0.8 x 0.2. The diagnosis was patellofemoral syndrome of the right and left knees. A November 2017 DBQ noted similar findings with range of motion studies showing flexion to 135 degrees and extension to 5 degrees. Suboptimal effort was noted. Repetitive use testing did not result in additional loss of function or range of motion. Pain was noted on examination in flexion and extension and caused functional loss. The Veteran reported that squatting was difficult, walking hurt, and he could not stand for very long. He did not report flare-ups. There was objective evidence of pain on passive range of motion testing and when the joint was used in nonweight-bearing and weight-bearing. The scarring on the knees was noted and none of the scars were painful or unstable or measuring greater than 39 square cm. The diagnosis was patellofemoral syndrome of the right and left knees with scars. The Veteran underwent an arthroscopic medial meniscectomy of the left knee in September 2019. Range of motion studies performed in November 2019 showed right knee range of motion from 0 to 120 degrees; and left knee range of motion from 10 to 95 degrees. Prior to July 12, 2021, based on the medical evidence of record, a rating higher than 10 percent is not warranted under Diagnostic Code 5003, as there is not x-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. See Diagnostic Code 5003 for degenerative arthritis; Diagnostic Code 5010 (arthritis due to trauma, substantiated by x-ray findings, rate as degenerative arthritis). A compensable rating also is not warranted under Diagnostic Code 5260, as limitation of motion was not limited to at least 45 degrees of flexion. The medical evidence shows that range of motion in the right knee was most severely limited to 135 degrees of flexion. These findings were considered in the context of the DBQ in November 2017 which showed objective evidence of pain on passive and active range of motion testing and when the joint was used in non-weight-bearing and weight-bearing. The examiner noted that pain was noted on examination in flexion and extension and caused functional loss in that squatting was difficult, walking hurt, and he could not stand for very long. Notwithstanding the findings of significant pain that contributed to functional loss, the range of motion in the right knee did not contribute to functional loss and does not result in a rating higher than 10 percent. The examination in November 2017 complied with the requirements of Correia v. McDonald, 28 Vet. App. 158 (2016); and Sharp v. Shulkin, 29 Vet. App. 26 (2017) in determining the then-current severity of the Veteran's right knee disability. In November 2019, the left knee most severely was limited to 95 degrees of flexion; but this still does not warrant a compensable rating for limited flexion under Diagnostic Code 5260. As for limitation of extension, as noted, noncompensable ratings are assigned effective May 28, 2014, on the basis of the DBQs showing extension limited to 5 degrees, which warrants a 0 percent rating under Diagnostic Code 5261. Separate evaluations may be assigned for both flexion and extension of the knee joint only where the evidence demonstrates that both limitations rise to a compensable degree (i.e., meet the criteria for a 10 percent rating or higher under both Diagnostic Codes 5260 and 5261). See VAOPGCPREC 9-2004. This applies even for the left knee, which, after the meniscus surgery in September 2019, had limitation of extension to 10 degrees, which warrants a 10 percent rating under Diagnostic Code 5261; but still did not have compensable limited flexion. As limitation of both extension and flexion did not rise to a compensable degree for the knees prior to July 12, 2021, only one single rating assignment may be awarded for limitation of motion symptomatology. Thus, the highest supportable rating for limitation of motion of the knee applies prior to July 12, 2021. Effective July 12, 2021, however, the date of the DBQ submitted by the Veteran, the medical evidence shows that in both knees the Veteran had limitation of flexion to 30 degrees, which warrants a 20 percent rating under Diagnostic Code 5260; and limitation of extension to 15 degrees, which warrants a separate 20 percent rating under Diagnostic Code 5257. Passive range of motion was the same as active range of motion. There was evidence of pain on weight-bearing, nonweight-bearing, and in active and passive motion. There was no additional loss of function or range of motion after three repetitions. The factors that contributed to functional loss included pain, fatigability, weakness, and lack of endurance. Based on the July 2021 DBQ, the Veteran's right and left knee disabilities warrant 20 percent ratings, but no higher, for limitation of flexion; and separate 20 percent ratings, but no higher, for limitation of extension, effective July 12, 2021. In addressing the new criteria for arthritis, effective February 7, 2021, the medical evidence shows that the Veteran's knee arthritis is degenerative (i.e., not posttraumatic). See, e.g., July 2021 DBQ. Thus, there is no change to the ratings assigned under the new criteria. 85 Fed. Reg. 76453 (Nov. 30, 2020) (codified at 38 C.F.R. § 4.71a, Diagnostic Code 5010 (2021)). The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. 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). The medical evidence does not show any ankylosis of the knees. Thus, a rating under Diagnostic Code 5256 does not apply. As for Diagnostic Code 5257, VAOPGCPREC 23-97 held that a claimant who has both arthritis and instability of the knee may receive two separate disability ratings under Diagnostic Codes 5003-5010 and Diagnostic Code 5257 (or under Diagnostic Codes 5258 or 5259) without violating the prohibition of pyramiding of ratings. The presence of instability of the knees may be established by lay evidence alone. See English v. Wilkie, 30 Vet. App. 347, 352 (2018). Most of the VA treatment records show that there is no objective evidence of instability in the right and left knees. See, e.g., DBQs dated in November 2014 and November 2017. However, the November 2014 DBQ noted that the Veteran had a meniscal tear in the right knee with frequent episodes of joint pain. The Veteran also underwent surgery to repair the medial meniscus in the left knee in September 2019 after slipping and falling at work. Examination of the left knee in September 2019 specifically noted that there was no instability in the left knee, however. The Veteran testified at the June 2021 Board hearing that he had buckling and falling with instability in the knees. See June 2021 Board hearing transcript, p. 18. The November 2017 DBQ noted that he constantly used a cane, due in part, to his knee pain. Under Diagnostic Code 5257, a 10 percent rating is warranted 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. Given that objective medical evidence is not necessarily required to establish lateral knee instability under Diagnostic Code 5257, pursuant to English v. Wilkie, 30 Vet. App. 347, 352-53 (2018), the Board resolves all doubt in the Veteran's favor that he had slight instability in the right and left knees, effective throughout the appeal. Based on the findings on the November 2014 DBQ of a meniscal tear with frequent episodes of joint pain, the November 2017 DBQ noting the Veteran's constant use of a cane due, in part, to his knee pain, the September 2019 treatment record noting a meniscal tear in the left knee, and the Veteran's testimony of experiencing his knees buckling and feeling unstable resulting in his falling, a separate rating for slight lateral instability of the right and left knees is warranted, effective May 28, 2014, the date of the Veteran's claim. The medical evidence within one year prior to May 28, 2014 does not show a separate rating for instability of the right and left knees is warranted. The next higher 20 percent rating is not warranted, as the evidence does not show moderate recurrent subluxation or lateral instability. In weighing the objective findings showing mostly no objective evidence of instability throughout the appeal (see, e.g., DBQs in November 2014 and November 2017, and September 2019 VA treatment record) with the 2014 and 2019 findings of meniscal tears in the right and left knees, respectively, as well as the medical findings of using a cane and subjective complaints of giving way, the evidence shows no more than slight instability in the right and left knees. With the change in regulations as outlined above effective from February 7, 2021, Diagnostic Code 5257 now contains two sections for rating other impairment of the knee. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The first is for recurrent subluxation or instability. The second is for patellar instability. In this regard, the November 2014 DBQ shows that the Veteran had a history of a meniscus tear in the right knee, and the VA examiner noted that the Veteran required the use of a cane, due, in part, for his knee in the November 2017 DBQ. The Veteran also reportedly had a meniscus tear with a surgery to repair it in September 2019 after a work injury. However, as noted, the DBQs prior to July 12, 2021 show that there is no objective or clinical evidence of instability in the right and left knees. The September 2019 VA treatment record also indicated that there was no evidence of instability in the left knee even with the meniscus tear. As noted above, the Board has accepted the Veteran's competent statements and testimony as probative subjective evidence of instability in the right and left knees prior to July 12, 2021. Nonetheless, regarding the version of Diagnostic Code 5257 in effect since February 7, 2021, a higher rating for recurrent subluxation or instability is not warranted prior to July 12, 2021, because the evidence does not show sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability or unrepaired or failed repair of complete ligament tear causing persistent instability, or a diagnosis of patellofemoral complex. Notably, diagnostic testing for stability on the DBQs prior to July 12, 2021 does not reveal any objective evidence of instability, which is probative evidence against a finding of persistent instability. Put another way, when multiple medical tests for instability fail to detect instability, the evidence strongly suggests that constant instability is not present. A higher 20 percent rating under the revised version of Diagnostic Code 5257 is therefore, not warranted, prior to July 12, 2021. Effective July 12, 2021, however, the DBQ submitted by the Veteran shows the Veteran had recurrent subluxation or persistent instability in both knees. He had been prescribed a brace by a medical provider and had recurrent patellar instability. The report also noted that the Veteran had a meniscal tear with frequent episodes of joint "locking," frequent episodes of joint pain, and frequent episodes of joint effusion. It was noted that the Veteran occasionally used a cane. These findings more closely approximate the criteria for 20 percent ratings under Diagnostic Code 5257, effective July 12, 2021. As the Veteran has been prescribed a brace for his recurrent patellar instability, these findings are more consistent with moderate instability under the criteria in effect prior to February 7, 2021. A rating higher than 20 percent is not warranted under the former criteria under Diagnostic Code 5257, as the medical evidence does not show severe recurrent subluxation or lateral instability. While the Veteran was prescribed a brace for the knees, he only occasionally used a cane; and prior examination had demonstrated that the cane also was for his back disability. See, e.g., November 2017 DBQ. The July 2021 DBQ also specified that the Veteran had patellar instability, which is significant for the change in regulations under Diagnostic Code 5257, effective from February 7, 2021. The revised criteria note that a 20 percent rating is provided for patellar instability when it is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. The next higher 30 percent rating is warranted for patellar instability when it is a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. In this regard, the service treatment records show the Veteran had cartilage surgery on his right knee in May 1983. He also had a scope performed on the left knee in service in March 1998 for a possible meniscus tear, as well as a meniscus repair to the left knee in September 2019, as noted. The July 2021 DBQ shows that the Veteran had patellar instability and that a provider had prescribed a brace. He also reportedly used a cane occasionally but there is no indication that a provider prescribed the cane for his knees. A previous November 2017 DBQ notes that the Veteran constantly used a cane for his knees and his back but there is no indication that the cane had been prescribed by a medical provider. Thus, the evidence does not rise to the criteria for a 30 percent rating for instability in the right and left knees, and more closely approximates the criteria for a 20 percent rating, effective July 12, 2021. A separate rating under Diagnostic Code 5258 for dislocated semilunar cartilage is not warranted, as the currently assigned ratings contemplate instability in the right and left knees and painful motion of the right and left knees due to arthritis. To assign a separate rating for dislocated semilunar cartilage with frequent episodes of locking, pain, and effusion would in this case be rating the same type of impairment under different diagnostic codes, which is impermissible under 38 C.F.R. § 4.14. Similarly, a separate rating under Diagnostic Code 5259 is not warranted as the Veteran already is assigned ratings for any resultant instability and painful motion in the right and left knees. The medical evidence does not show impairment of the tibia and fibula warranting a rating under Diagnostic Code 5262. The medical evidence also does not show genu recurvatum under Diagnostic Code 5263. Thus, in reviewing the medical evidence of record, the Board finds that the preponderance of the evidence is against a rating higher than 10 percent for limitation of motion of the right and left knees prior to July 12, 2021. However, effective July 12, 2021, the medical evidence shows that ratings of 20 percent for limitation of flexion are warranted; and ratings of 20 percent are warranted for limitation of extension. Also, effective May 28, 2014, separate ratings of 10 percent, but no higher, are warranted for right and left knee instability; and effective July 12, 2021, 20 percent ratings are warranted for right and left knee instability. The Board acknowledges the Veteran's previous lay reports of symptoms and that there was functional loss due to pain and instability. These statements have been considered in the ratings assigned. To the extent that any higher ratings are not assigned, 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. Service Connection 4. Entitlement to service connection for bilateral carpal tunnel syndrome with hand swelling The Veteran contends that he has bilateral carpal tunnel syndrome as a result of his time in service, specifically due to his military occupational specialty (MOS) which required repetitive, manipulative movements. He testified that he had had problems with his hands and swelling since active duty service. See June 2021 Board hearing transcript, p. 12. The Board concludes that the Veteran has a current disability that is related to in-service injury. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). A private treatment record dated in April 2014 notes that the Veteran was seen for complaints of bilateral hand numbness and tingling. He was diagnosed with carpal tunnel syndrome per electrodiagnostic studies. A July 2015 private treatment record also noted that the Veteran had undergone electromyographic (EMG) studies, which showed mild left median focal neuropathy at the wrist consistent with carpal tunnel syndrome and moderate right median focal neuropathy at the wrist consistent with carpal tunnel syndrome. The Veteran's DD-Form 214 shows that his MOS for 20 years in the United States Navy was a Systems Organizational Career Maintenance Technician. Thus, his reports of repetitive use injuries to his wrists in service are consistent with the circumstances of his service as a maintenance technician. See 38 U.S.C. § 1154(a). Also, during service, the Veteran was seen for complaints of a left thumb injury in August 1983. A March 1988 treatment record shows that the Veteran had complaints of bumps on the right 4th finger and base of the 2nd phalange similar to Heberden's nodes. An April 1988 treatment record notes complaints of pain and swelling at the base of the 4th finger and 2nd phalanx; x-rays were normal. In January 1990, an emergency room record shows the Veteran was seen for an abrasion to the right thumb. An August 1993 treatment records shows the Veteran was treated for cutting his thumb and 5th finger on the right hand. At separation from service in April 2003 the Veteran reported that he had fractured his right hand at the little knuckle. Thus, the question becomes whether the current disability is related to service, including his duties in service and the reported injuries. On this question there are opinions in favor of and against the claim. A November 2017 VA examination report shows that the examiner found no direct correlation linking any peripheral neuropathy to include carpal tunnel syndrome to the Veteran's time in active duty. However, the examiner did not comment on the Veteran's duties in service or his complaints of repetitive use injuries as a maintenance technician. Also, there was no rationale provided for the medical opinion. Thus, the probative value of the November 2017 VA medical opinion is not high. The Veteran submitted a private medical opinion dated in July 2021, which noted that the Veteran's duties as an aviation structural mechanic involved maintaining all aircraft maintenance and auxiliary hydraulic power systems, actuating subsystems, and landing gear. It was noted that because of his position he was responsible for maintenance on the aircraft fuselage wing airfoils associated with fixed and movable surfaces and flight controls. The clinician indicated that according to the medical literature by Michigan Surgery Specialists, P.C., a person in automotive work is at risk for developing carpal tunnel syndrome because of the required mechanical tasks regularly performed which require repetitive movements of the hands. It also was noted that the constant and repetitive task from such work cause stress that inflames the tendons in the wrists, leading to swelling in the hands, which the Veteran also had. The clinician indicated that the EMGs revealed mild left and moderate right medial focal neuropathy consistent with bilateral carpal tunnel syndrome. It was noted that prior to service there was no evidence suggesting bilateral hand/ wrist pain or other pertinent symptoms. The Veteran reported that he worked after service as a mechanic but that he was not required to use his hands, wrists, or fingers as regularly as he did while in the service. It was noted that the Veteran spent approximately 20 years in the Navy performing aviation structural mechanic work during which time he was required to use his hands, wrists, and fingers on a near-continuous basis while working. Therefore, the clinician found that considering the Veteran's medical history and all potential etiologies, the Veteran's bilateral carpal tunnel syndrome is at least as likely as not a result of his time in service. In weighing the medical evidence of record, the preponderance of the evidence is in favor of the Veteran's claim that his current bilateral carpal tunnel syndrome with hand swelling is related to service, including his approximately 20 years in the Navy performing aviation structural mechanic work during which time he was required to use his hands, wrists, and fingers on a near-continuous basis while working. Accordingly, after resolving any doubt in favor of the Veteran, the Board finds that service connection for carpal tunnel syndrome with hand swelling is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for bilateral plantar fasciitis with bone spurs The Veteran contends that his plantar fasciitis with bone spurs is related to his military service. He testified at the Board hearing that his flight deck boots issued in service back in the early 1980s and 1990s did not have cushion on the inside and had stiff leather at the heel, which is where he developed a bone spur encasing his Achilles tendon. See June 2021 Board hearing transcript, p. 8. He further noted that he had swelling in his ankles and feet since injury in service in July 1989 involving rubbing of the toes in the boot and trauma to the fifth toe on the right foot, which is noted in his service treatment records. Id. at 8-9. The Board concludes that the Veteran has a current disability that is related to in-service injury. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). VA treatment records show the Veteran has a current diagnosis of chronic plantar fasciitis dated in August 2015. An August 2015 VA treatment record also notes a plantar calcaneal spur likely causing heel pain. A September 2015 VA treatment record notes that the Veteran complained of bilateral foot pain that had been present for 15 plus years when he was injured in the Navy. During service, the Veteran was seen for twisting his right ankle playing basketball in September 1990. He had mild edema at the lateral malleolus and tenderness. A separate September 1990 treatment record notes right ankle pain with old avulsion injury to the medial malleolus. A December 1992 treatment record notes that he had injury to the left big toe and the toenail fell off. The Veteran also is competent to state that he experienced foot and heel discomfort related to his deck shoes while serving in the Navy. Thus, the question becomes whether the current disability is related to service. The Veteran submitted a private medical opinion in July 2021, which noted that the Veteran suffered from bilateral plantar fasciitis with bone spurs that had developed as a result of injuries sustained during his time in service. The clinician noted that specifically, the Veteran had sustained numerous injuries to his ankle, knees, and toe during service. In September 1990 he was examined on duty for an injury to his ankle while playing basketball with edema surrounding the ankle. The clinician noted that according to the medical literature by the American College of Foot and Ankle Surgeons, an injury, such as an ankle sprain, produces inflammation and swelling, which can compress the nerve and plantar fascia, which, in turn, tears or damages the tissues causing heel pain. The clinician indicated that a physical examination and magnetic resonance imaging (MRI) in May 2014 showed mild partial thickness tearing of the anterior talofibular ligament that appeared to be chronic. An August 2015 MRI of the right ankle showed edema within the medial ankle, subchondral edema along the first and second digits, and edema about the Achilles tendon, among others, with a history of painful retrocalcaneal spur. The clinician found that ultimately, considering the relevant medical history and literature, the Veteran's bilateral plantar fasciitis with bone spurs was at least as likely as not a result of his time in service, and the injuries sustained at that time. There are no other medical opinions of record addressing the etiology of the Veteran's bilateral plantar fasciitis with bone spurs. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current bilateral plantar fasciitis with bones spurs is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for bilateral plantar fasciitis with bone spurs is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Whether new and material evidence was received to reopen entitlement to service connection for hearing loss Before adjudicating the Veteran's claim on the merits, the record shows that the Veteran's service connection claim for bilateral hearing loss was previously denied in a final decision. Thus, the threshold issue of whether new and material evidence has been received to reopen the claim must be addressed. A claimant may reopen a finally adjudicated claim by submitting new and material evidence. 38 U.S.C. §§ 5108, 7103, 7104, 7105; 38 C.F.R. §§ 3.156, 20.1100. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of sustaining the claim. 38 C.F.R. § 3.156(a). New and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof. See Shade v. Shinseki, 24 Vet. App. 110, 120 (2010). When determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. The only exception would be where evidence presented is inherently incredible. Justus v. Principi, 3 Vet. App. 510 (1992). The Veteran originally filed a service connection claim for bilateral hearing loss in July 2011. The service treatment records showed the Veteran underwent several audiograms as part of collecting hearing conservation data in service with significant threshold shifts noted as ranging from 15 to 5 decibels from June 1983 to March 2003. He had complaints of hearing loss at separation from service but there were no audiometric findings that met the criteria for hearing loss in service. Also, a post-service August 2011 VA examination report showed normal hearing loss for VA purposes. See 38 C.F.R. § 3.385. In an August 2011 rating decision, the RO denied service connection for bilateral hearing loss, finding that the evidence of record did not show audiometric findings that met the criteria for a grant of service connection for hearing loss. As the Veteran did not appeal the August 2011 rating decision, it is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted a petition to reopen his service connection claim for bilateral hearing loss in May 2014. He underwent a VA examination in May 2018, which showed that the Veteran still did not have a hearing loss disability for VA purposes. See 38 C.F.R. § 3.385. However, the Veteran submitted a private medical opinion in July 2021 that he presently suffered from bilateral hearing loss that was at least likely as not related to his loud military noise exposure. The Board finds that this evidence is new and material. Specifically, medical evidence showing a finding of hearing loss related to military service was not previously considered by agency decisionmakers, is not cumulative or redundant, relates to unestablished facts necessary to substantiate the Veteran's claim, and raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.303. Accordingly, the Veteran's service connection claim for bilateral hearing loss is considered reopened. Shade v. Shinseki, 24 Vet. App. 110 (2010). REASONS FOR REMAND 1. Entitlement to service connection for bilateral hearing loss is remanded. The Veteran submitted a private medical opinion that his bilateral hearing loss is related to his military service but did not provide an audiogram that shows he has a hearing loss disability for VA purposes. The Board cannot make a fully-informed decision based on the evidence of record. 2. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. The record shows that even prior to the grants in this decision, the Veteran met the criteria for a TDIU on a schedular basis, effective May 18, 2018. He also submitted a private medical opinion in July 2021 that his service-connected disabilities prevented him from working. However, it is not clear from the record when, if ever, the Veteran stopped being gainfully employed. The Veteran testified at the Board hearing that he stopped working on a full-time basis in 2015 or 2016. However, vocational rehabilitation records show that the Veteran was still employed as late as February 2020. The Veteran submitted a Rehabilitation Needs Inventory in January 2020 that he was working full-time as a truck driver since January 2019 with an average gross monthly salary of $3,200. Previously, he noted that he had worked full-time from February 2018 to January 2019 as a truck driver with an average gross monthly salary of $3,600. Prior positions included maintenance technician since February 2017 on a full-time basis with average monthly salary ranging from $2,000 to $3,000. Also, in an email communication with a Vocational Rehabilitation Counselor on February 7, 2020, the Veteran noted that he would be starting a new job at a hospital and would not be able to take any time off from work for appointments and needed to pull his application for vocational rehabilitation. The Veterans Law Judge who conducted the Board hearing in June 2021 suggested that the Veteran submit an updated VA-Form 21-8940 to clarify the dates that the Veteran stopped being gainfully employed. However, the Veteran did not do so. The Veteran is requested to resubmit the VA-Form 21-8940 to clarify when he stopped working full-time and to provide the information concerning dates of employment and salary received for his work since 2014. 3. Entitlement to special monthly compensation (SMC) based on the need of aid and attendance of another person is remanded. The issue of entitlement to SMC based on the need of aid and attendance of another person has been raised by the record. See, e.g., August 2018 in-home caregiver assessment. While the issue has been raised, the Board cannot make a fully informed decision on the issue of entitlement to SMC based on the need for aid and attendance of another person because no VA examiner has opined whether the Veteran is in need of aid and attendance due to his service-connected disabilities. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a TDIU claim form (VA Form 21-8940) with updated information concerning his employment, including part-time employment since 2014, and including salaries received. The AOJ should then undertake all indicated development to obtain all related employment information from the reported employers. 2. Schedule the Veteran for a VA examination for his bilateral hearing loss. The examiner must review the claims file. The examiner is asked to examine the Veteran's audiometric findings to determine whether he has a hearing loss disability as defined by 38 C.F.R. § 3.385. If so, the examiner is asked to determine whether the hearing loss disability is at least as likely as not related to service, including exposure to acoustic trauma in service. Provide a rationale to support the opinion(s). 3. Schedule the Veteran for an examination by an appropriate clinician to determine whether the Veteran has the need for aid and attendance of another person due to his service-connected disabilities. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Sarah B. Richmond, 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.