Citation Nr: 21066909 Decision Date: 11/02/21 Archive Date: 11/02/21 DOCKET NO. 15-23 182A DATE: November 2, 2021 ORDER Entitlement to an increased rating in excess of 10 percent for left knee chondromalacia is denied. Entitlement to a separate 20 percent rating for left knee meniscal damage from October 14, 2020, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to a 20 percent, but not higher, rating for residuals of a left ankle injury is granted, effective from October 14, 2020, subject to the law and regulations governing the payment of monetary benefits. Entitlement to service connection for a left foot disability, to include as secondary to his service-connected left knee and ankle disabilities, is denied. REMANDED Entitlement to service connection for a chronic liver disorder, with elevated ALT readings, is remanded. FINDINGS OF FACT 1. The Veteran's left knee chondromalacia is not productive of ankylosis, flexion limited to 45 degrees or less, extension limited to 10 degrees or more, instability, malunion or nonunion of the tibia and fibula, genu recurvatum, or the functional equivalent thereof. 2. Effective from October 14, 2020, the is medical evidence demonstrating left knee meniscal damage and symptoms consistent with that damage. 3. Effective from October 14, 2020, the Veteran's residuals of a left ankle injury that include extension limited to 5 degrees with pain is consistent with marked limitation of ankle motion. 4. The Veteran does not have a current disability associated with his left foot. CONCLUSIONS OF LAW 1. The criteria for a disability rating in excess of 10 percent for left knee chondromalacia have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.71a, Diagnostic Code (DC) 5260. 2. The criteria for a separate 20 percent rating for left knee meniscal damage, effective from October 14, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.71a, Diagnostic Code (DC) 5258. 3. The criteria for entitlement to a 20 percent, but not greater, rating for residuals of a left ankle injury, effective from October 14, 2020, have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 4.14.14, 4.71a, Diagnostic Code (DC) 5271. 4. The criteria for service connection for a left foot disability to include as secondary to left knee and ankle disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1994 to February 1997. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) Louisville, Kentucky. In May 2019, the Veteran testified at a Board hearing conducted by the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the Veteran's VA claims file. These matters, inter alia, were addressed and remanded by the Board in a December 2019 decision. The requested development, to include VA examinations and etiological opinions, has been completed. The matters are again before the Board for additional appellate consideration. Increased Rating Generally, disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.10. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in such cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See DeLuca v. Brown, 8 Vet. App. 202 (1995). The Court has clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, in Mitchell, the Court explained that, pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, and less or more movement than is considered normal, weakened movement, excess fatigability, and pain on movement (with swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing. Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The Board observes that the words "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. It should also be noted that use of descriptive terminology such as "mild" by medical examiners, although an element of evidence to be considered by the Board, is not dispositive of an issue. All evidence must be evaluated in the process of arriving at a decision regarding an increased rating. 38 U.S.C. § 7104(a); 38 C.F.R. §§ 4.2, 4.6. In considering the evidence in any given appeal, it is the responsibility of the Board to weigh the evidence and decide where to give credit and where to withhold the same and, in so doing, accept certain medical opinions over others. Schoolman v. West, 12 Vet. App. 307, 310-11 (1999). In this regard, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson. Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Evans v. West, 12 Vet. App. 22, 30 (1998). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to an increased rating in excess of 10 percent for left knee chondromalacia. In this case, the Veteran seeks an increased rating in excess of 10 percent for his left knee chondromalacia. The Veteran has been in receipt of a 10 percent disability rating under DC 5299-5260 since March 20, 1999. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the assigned rating; the additional code is shown after the hyphen. Under DC 5260, for limitation of flexion of the leg, it provides that where flexion is limited to 60 degrees, a 0 percent rating is provided; when flexion is limited to 45 degrees, 10 percent is assigned; when flexion is limited to 30 degrees, 20 percent is assigned; and when flexion is limited to 15 degrees, 30 percent is assigned. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5260). The Board notes that full range of motion of the knee consists of zero (0) degrees extension and 140 degrees flexion. 38 C.F.R. § 4.71, Plate II. Other potentially applicable diagnostic codes for evaluation the right leg disability include the following diagnostic codes. Under DC 5010, a maximum 20 percent rating is warranted for x-ray evidence involving 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations. Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a). DC 5256, for ankylosis of the knee: provides that favorable ankylosis of either knee warrants a 30 percent evaluation. Ankylosis is considered to be favorable when the knee is fixed in full extension, or in slight flexion at an angle between 0 and 10 degrees. A 40 percent evaluation requires that the knee be fixed in flexion at an angle between 10 and 20 degrees. When the knee is fixed in flexion between 20 and 45 degrees, a 50 percent rating is assigned. A 60 percent rating is warranted for extremely unfavorable ankylosis, with the knee fixed in flexion at an angle of 45 degrees or more. Id. DC 5257 provides the rating criteria for impairment of the knee manifested by recurrent subluxation and lateral instability. Under this diagnostic code provision, a 10 percent disability rating is warranted where there is slight recurrent subluxation or lateral instability of the knee. A 20 percent disability rating is warranted where the recurrent subluxation or lateral instability of the knee is moderate. The maximum 30 percent disability rating is warranted where there is severe recurrent subluxation or lateral instability of the knee. 38 C.F.R. § 4.71a, DC 5257. Under the new DC 5257 regulations, a 10 percent rating is warranted for a sprain, incomplete tear, or complete tear causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. A 20 percent rating is warranted for either sprain, incomplete ligament tear, or repaired tear causing persistent instability, and a provider prescribes a brace and/or assistive device OR unrepaired or failed repair of complete ligament tear causing instability, and a medical provider prescribes an assistive device. A 30 percent rating is warranted for an unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribes both an assistive device and bracing for ambulation. In the alternative, for patellar instability, a 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability that does not require a prescription for a brace, cane, or walker. A 20 percent rating is warranted when the condition after a surgical repair requires a prescription from a medical provider for one of the following: brace, cane, or walker. A 30 percent rating is warranted when the condition after surgical repair requires a brace and or cane or walker. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5257) (effective February 7, 2021). Under DC 5258, a maximum 20 percent rating is warranted for evidence of dislocated, semilunar, cartilage, with frequent episodes of "locking," pain, and effusion into the joint. Id. Under DC 5259, provides that a 10 percent rating is assigned for cartilage, semilunar, removal of, symptomatic. This code does not provide for a disability rating in excess of 10 percent. Id. Under DC 5261, for limitation of the extension of the leg, when there is limitation of extension of the leg to 5 degrees, a zero percent rating is assigned; when the limitation is to 10 degrees, a 10 percent rating is assigned; when the limitation is to 15 degrees, 20 percent is assigned; when extension is limited to 20 degrees, 30 percent is assigned; when extension is limited to 30 degrees, 40 percent is assigned; and when it is limited to 45 degrees, 50 percent is assigned. Id. For painful motion with any form of arthritis, the Veteran is entitled to at least the minimum compensable rating. 38 C.F.R. § 4.59. The same is true for painful motion in non-arthritis contexts when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). VA General Counsel also held in VAOPGCPREC 23-97 that a claimant who has arthritis and also instability of the knee may be rated separately under diagnostic codes 5003 and 5257. General Counsel stated that when a knee disorder is already rated under DC 5257, the veteran must also have limitation of motion which at least meets the criteria for a zero percent rating under DC 5260 (flexion limited to 60 degrees or less) or 5261 (extension limited to 5 degrees or more) in order to obtain a separate rating for arthritis. General Counsel subsequently held in VAOPGCPREC 9-98 that a separate rating for arthritis could also be based on X-ray findings and painful motion under 38 C.F.R. § 4.59; see also Degmetich v. Brown, 104 F.3d 1328, 1331 (Fed. Cir. 1997). Where additionally disability is shown, a veteran rated under DC 5257 can also be compensated under 5003, and vice versa. Moreover, an evaluation of a knee disability under Diagnostic Codes 5260 or 5261 does not preclude a separate evaluation under other diagnostic codes, such as 5258 or 5259. See Lyles v. Shulkin, 29 Vet. App. 107 (2017). However, the Court indicated that such symptoms must be distinct and separate to warrant separate ratings under different DCs, i.e., the same manifestation of disability may not be compensated under more than one DC. Id. Analysis Turning to the pertinent medical evidence the Board finds the preponderance of the evidence is against the assignment of a disability rating in excess of 10 percent for left knee chondromalacia. First, the Veteran was afforded an original VA examination in February 2014. The examiner diagnosed the Veteran with chronic musculoligamentous strain. The Veteran did not report flare-ups. Left knee flexion was measured to be to 100 degrees with extension to 0. There was no additional loss of range of motion (ROM) following repetitive use. Furthermore, there is no evidence of anterior instability, posterior instability, medial-lateral instability, or patellar subluxation/dislocation. Imaging studies did not reveal any degenerative arthritis. A March 2018 medical note then indicates that the Veteran underwent a left knee arthroscopy. There are multiple complaints of left knee pain to include "giving out," locking, and with all conservative treatment exhausted, a left knee arthroscopy was recommended. Left knee ROM was noted with be "full," with no effusion, and a normal gait. The diagnosis was left knee internal derangement. The Veteran was then afforded a VA examination in April 2019. The examiner confirmed the diagnosis of left knee chondromalacia. Per the Veteran's self-reported medical history, he reported that he injured his left ankle in 1994 and, to compensate for the injury, he developed problems with his left knee. He reported that he treated his left knee disability conservatively throughout service and in April 2018 he underwent a left knee arthroscopy. The examiner notes the severity of the Veteran's disability to be moderate, limits, but does not prevent activity. Left knee range of motion (ROM) was found to be abnormal. Forward flexion is 0 to 90 degrees with extension is to 0 degrees with pain noted on examination causing functional loss. Notably, the Veteran is unable to squat or kneel. Passive range of motion is the same as active ROM. The Veteran can perform repetitive-use testing with at least three repetitions and no loss in range of motion or functional loss. Other contributing factors include swelling, disturbance of locomotion, and interference with standing. There is no evidence of ankylosis, recurrent subluxation, lateral instability, persistent instability, recurrent patellar dislocation, shin splints, or meniscus tear. Imaging studies were conducted and there is no evidence of degenerative or traumatic arthritis. Following the Board's December 2019 remand directives, an additional VA examination was provided on October 14, 2020. Here, the examiner noted the Veteran's diagnosis to be left knee chondromalacia with evidence of meniscal damage and symptoms associated with such damage. The Veteran reports daily flare-ups with increased pain, swelling, and stiffness. The Veteran's left knee ROM was considered abnormal. Forward flexion is 0 to 130 degrees with extension to 0 degrees. The Veteran can perform repetitive-use testing with at least three repetitions and measured flexion of 5 to 125 and extension is to 5 with contributing pain and weakness. With repetitive use over time, functional loss is reflected by pain and weakness, with flexion limited to 5 to 125 degrees and extension limited to 5 degrees. During flare-ups, flexion is limited to 5 to 120 degrees and extension is limited to 5 degrees. There are no additional contributing factors of disability. There is no evidence of ankylosis, recurrent subluxation, lateral instability, persistent instability, recurrent patellar dislocation, or shin splints. A December 2014 MRI revealed a small oblique tear of the posterior horn of the lateral meniscus in both knees. However, the examiner notes the left knee meniscus tear to be a data entry error as the Veteran's medical record notes the right knee meniscal tear prior to a scheduled surgery in August 2017. Imaging studies conducted in December 2014 revealed degenerative arthritis in the left knee. Medical notes from November 2020 indicate the Veteran underwent bilateral knee injections to help alleviate his pain. The note states the Veteran's measured flexion is to 125 degrees and extension to 0 degrees. An additional VA examination was conducted in May 2021. The examiner diagnosed the Veteran with bilateral knee meniscal tear, bilateral shin splints, and left knee chondromalacia. The Veteran self-reported moderate flare-ups that occur few times monthly that last a few hours to a few days. He reported functional loss resulting in difficulty to walk on incline, climb in/out of machinery, difficulty in some daily activities, and prolonged use leads to drop foot. Forward flexion is measured to be to 120 degrees and extension is measured to be to 0 degrees with pain noted on flexion. Passive ROM was noted to be the same as active ROM. There was no change in ROM following observed repetitive use but after repeated use over time and during flare-ups flexion decreased to 115 degrees. There is no evidence of ankylosis, recurrent subluxation, lateral instability, persistent instability, ligament tear, or recurrent patellar instability. The examiner found evidence of "shin splints" with treatment for less than 12 consecutive months. Given the evidence, the Board finds a higher rating or additional ratings are not warranted for left knee disability based on limited motion or instability. First, there is no evidence of ankylosis in the left knee. Thus, no additional rating under DC 5256 is warranted. Next, under DC 5260, the Veteran's current diagnostic rating, for limitation of flexion of the leg, the Veteran's ROM in April 2019 for left knee flexion is measured to be 0 to 90 degrees, passive ROM is unchanged, as is after three repetitive motions and during flare-ups. In February 2014, forward flexion is to 100 degrees. In October 2020, his forward flexion is 0 to 130 degrees. After repetitive-use testing flexion is 5 to 125. With repetitive use over time flexion is 5 to 125 degrees. During flare-ups, flexion is limited to 5 to 120 degrees. In November 2020, flexion is 0 to 125 degrees. In May 2021, forward flexion is measured to be to 120 degrees. Passive ROM was noted to be the same as active ROM. There was no change in ROM following observed repetitive use but after repeated use over time and during flare-ups flexion decreased to 115 degrees. Thus, the evidence does not even reflect that the Veteran's left knee disability was productive of limitation of right knee flexion to at least 45 degrees (the level of impairment required for a compensable rating under DC 5260). There is also no additional uncompensated limitation of motion that can provide a basis for an even higher rating under DeLuca. Under 5261, for limitation of extension, Veteran's ROM for left knee extension in February 2014 was to 0 degrees, in April 2019 is measured to be 0 degrees, passive ROM is unchanged, as is after three repetitive motions and during flare-ups. In October 2020, his extension is 0 degrees and after repetitive-use testing with at least three repetitions and measured an extension to 5 degrees. With repetitive use over time, extension is limited to 5 degrees. In May 2021, extension was measured to be to 0 degrees, passive motion, observed repetitive use, repeated use over time, and during any flare-ups extension remained unchanged. A 10 percent rating is warranted when the limitation is to 10 degrees and to warrant an increase rating to 20 percent for left and right knee extension, there must be evidence of limitation of extension to 15 degrees. Thus, extension to a compensable level has not been approximated and there is therefore once again no additional uncompensated limitation of motion that can service as a basis for an even higher rating under DeLuca. Here, the Veteran's left knee extension is consistent with a 10 percent disability rating. With regard to flexion and extension, the respective limitation of ROM for the left knee does not reach the level of impairment required for additional or higher disability ratings. Furthermore, under DC 5257, the Veteran's March 2018 medical record, his April 2019, October 2020, and May 2021 VA examinations do not indicate the Veteran has a sprain, incomplete ligament tear, or complete tear causing persistent instability, without a prescription from a medical provider for an assistive device or bracing for ambulation. The Veteran does not experience impairment of the knee manifested by recurrent subluxation or lateral instability. However, the Board notes that at the Veteran's October 14, 2020, examination the examiner specifically noted that there was evidence of a left meniscal tear and that there were symptoms consistent with such damage, noting symptoms of swelling and stiffness, which the Board finds can provide a basis for an additional 20 percent rating under Diagnostic Code. The Board further notes that this diagnosis is again repeated at the time of the Veteran's more recent examination in May 2021. The Board will therefore give the Veteran the benefit of the doubt, and find that effective from October 14, 2020, there is sufficient evidence of left knee meniscal damage and corresponding symptoms to warrant a separate 20 percent rating for left meniscal damage from that date. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Based on the foregoing, the Board finds that the preponderance of the evidence is against entitlement to a rating in excess of 10 percent for left knee chondromalacia but supports a separate 20 percent rating for left knee meniscal damage from October 14, 2020. 38 U.S.C. § 5107; 38 C.F.R. § 4.3, 4.7. 2. Entitlement to an increased rating in excess of 10 percent for residuals of a left ankle injury. The Veteran seeks an increased rating in excess of 10 percent for residuals of a left ankle injury. The Veteran's disability is rated under DC 5271 with an effective date of February 1997. Prior to February 7, 2021, a 10 percent rating was assigned for moderate limitation of motion, and a maximum 20 percent rating is warranted for marked limited motion of the ankle. 38 C.F.R. § 4.71a, DC 5271. Normal range of motion of the ankle includes plantar flexion from 0 degrees to 45 degrees and dorsiflexion (extension) from 0 degrees to 20 degrees. 38 C.F.R. § 4.71a, Plate II. Under the rating criteria in effect from February 7, 2021, a 10 percent rating is warranted with moderate limited motion (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion). Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76463 (Nov. 30, 2020) (to be codified at 38 C.F.R. § 4.71a, DC 5271). A 20 percent rating is warranted for marked limitation (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion). Id. Analysis First, the Veteran was afforded a VA examination in February 2014. The examiner diagnosed the Veteran with status post eversion injury and degenerative joint disease. Medical history included that the Veteran sustained a severe eversion injury of the left ankle which tore ligaments during a distance run. The Veteran did not report any flare-ups. Normal endpoint of left ankle plantar flexion is to 45 while plantar dorsiflexion (extension) is 20 degrees. Left ankle flexion is measured to be to 30 degrees while extension is to 20 degrees. After repetitive use testing there was no change in ROM. There is no evidence of joint instability or ankylosis. An additional VA examination was provided on October 14, 2020. The examiner confirmed the residuals of a left ankle injury to include a diagnosis of degenerative arthritis and acute ankle sprain, resolved. Measured ROM for the Veteran's left ankle for flexion was measured to be 0 to 30 degrees with extension measured to be 0 to 10 degrees. Both flexion and extension exhibited pain on ROM. After repetitive use testing, flexion remained the same while extension decreased to 5 degrees. After repeated use over time, flexion remained unchanged while extension decreased to 5 degrees. During a flare-up, flexion decreased to 25 degrees while extension decreased to 5 degrees. There is no evidence of ankylosis, instability, or dislocation. The examiner found no evidence of shin splints, stress fracture, achilles tendon rupture, malunion of calcaneus, or talectomy. Imaging studies revealed degenerative arthritis of the left ankle. Functional loss includes hinderance of the Veteran's ability to squat, stoop, bend, knee, or walk for prolonged periods of time requiring frequent rest breaks and repositioning. The most recent VA examination was provided in May 2021. The examiner noted the diagnosis of residuals of a left ankle injury and a new diagnosis of shin splints. The Veteran reported flare-ups occurring weekly that are moderate in severity and alleviated by rest, ice, and elevation. Measured ROM for flexion is to 25 degrees with extension to 10 degrees. Passive ROM is the same as active ROM. After repetitive use, there is no change in ROM. After repeated use over time, flexion is measured to be to 20 degrees while extension is measured to be to 5 degrees. During flare-ups, ROM measurements were 20 degrees for flexion and 5 degrees for extension. There is no evidence of ankylosis, no joint instability, however, the examiner noted the Veteran has shin splints requiring treatment for less than 12 consecutive months. The Veteran wears a left foot brace due to foot drop and wears a knee brace occasionally. Based on the evidence, the Board finds an increased rating of 20 percent for residuals of a left ankle fracture is warranted. The Veteran's current 10 percent disability rating under 5271 considers limitation of motion of the left ankle. To warrant a 20 percent rating under the criteria in effect prior to February 7, 2021, there must be marked limitation of motion. Under the criteria in effect from February 21, 2021, there must be marked limitation of motion, which is defined as less than 5 degrees dorsiflexion and less than 10 degrees plantar flexion. In this regard, with evidence of limited extension to 5 degrees with use as of the time of the Veteran's October 14, 2020, examination, while the Board may have been precluded from assigning a 20 percent rating under the new rating criteria, the Board finds that it may give the Veteran the benefit of the doubt under the older rating criteria, and assign a 20 percent rating for his limited extension to 5 degree with flare-ups and repetitive use. Under 38 C.F.R. §§ 4.40 and 4.45, and the decision in DeLuca, the Board is required to consider the Veteran's pain, swelling, weakness, and excess fatigability when determining the appropriate disability evaluation for a disability using the limitation of motion diagnostic codes. DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995). During his VA examinations, as noted above, that after repetitions and during flare-ups, his ROM decreases to 5 degrees extension and in consideration of such limitation and pain, the Board has assigned the highest rating for marked limitation under former Diagnostic Code 5271. Therefore, the newly assigned 20 percent rating has fully contemplated the Veteran's pain on functional use. Additionally, the Board has considered other applicable rating codes under which to assign separate or higher ratings. The medical evidence does not demonstrate that he suffers from ankylosis of the subastragalar or tarsal joint, or malunion of the os calcis or astragalus, or that he had an astragalectomy. 38 C.F.R. § 4.71a, DCs 5272, 5273, 5274, 5284. Yancy v. McDonald, 27 Vet. App. 484 (2016). Further, although there is evidence of degenerative or traumatic arthritis, a separate rating under DC 5003 is not warranted as it would evaluate the same limitation of motion contemplated by his new rating under DC 5271. This assignment would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. Accordingly, the Board finds separate ratings are not warranted. In sum, the evidence supports a 20 percent, but not higher, rating for the Veteran's residuals of a left ankle injury. TDIU Lastly, the Board notes that in Rice v. Shinseki, 22 Vet. App. 447 (2009), the Court held that a claim for a total disability based on individual unemployability (TDIU) is considered a component of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. Here, no claim has been raised by the Veteran or the record. Also, the Veteran's most recent examination reflects that he continues to have a gainful occupation as working with explosives in mining, and while he may have missed some time from this position due to his knee, ankle, and other service-connected disabilities, there is no indication that he is precluded from engaging in the activities of this profession due to these symptoms. Therefore, the Board finds that a TDIU claim under Rice has not reasonably been raised in conjunction with the current claim for a higher rating and need not be addressed further herein. Service Connection In order to establish service connection for a claimed disability, the following three elements must be satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship (nexus) between the present disability and the disease or injury incurred or aggravated during service. Hickson v. West, 12 Vet. App. 246 (1999). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b), Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge from service when all of the evidence, including lay evidence, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the present of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Although lay persons are considered competent to provide opinions on some medical issues, some medical issues fall outside of the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011). 3. Entitlement to service connection for a left foot disability, to include as secondary to his service-connected left knee and ankle disabilities. The Veteran seeks service connection for a left foot disability. Per the Board's remand directives, the Veteran was provided a VA examination and etiological opinion in October 2020. During the examination, the examiner noted the Veteran does not have a current left foot diagnosis outside of his currently service-connected ankle disability. The Veteran did not report any pain on use, pain on manipulation, swelling, functional loss, or impairment of his left foot. In the examiner's opinion, they stated that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or caused by the Veteran's service-connected disabilities to include left knee and ankle. The examiner provided that the "Veteran has no complaints regarding the left foot." The examiner found a diagnosis of pes planus (flat foot) and plantar fasciitis of the right foot. However, the Veteran's right foot disability is not currently on appeal. The Board concludes that the Veteran does not have a current diagnosis related to the left foot and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In finding that no current disability is present, the Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), which held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. In this case, however, the Veteran has been separately diagnosed with a left ankle disability and is currently in receipt of a 20 percent disability rating. While there is clearly some functional impairment associated with that disability, there is no such impairment specific to the left foot. As no current disability has been established, service connection is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a chronic liver disorder, with elevated ALT readings, is remanded. The Veteran seeks service connection for a chronic liver disorder with elevated ALT readings. During the Veteran's hearing with the undersigned Veterans Law Judge, he testified that he spent six months working in the hazmat pharmacy and six months in the tool room during active duty. He testified that he was a regular blood donor until he received a letter saying that, due to his elevated liver enzymes, he was no longer able to donate blood. After a review of the evidence, the examiner noted that the Veteran experienced a traumatic injury of the left ankle beginning a "cascade of unfortunate events" resulting in multiple complications. Due to his injury, the Veteran was reassigned to a duty assignment in the tool room and hazmat pharmacy which led to a diagnosis of elevated liver enzymes requiring liver biopsy with routine monitoring of labs. The examiner noted that on average, every three months for the next several years, the Veteran underwent a series of monitoring tests. The Veteran underwent a liver biopsy in July 2012 and an ultrasound of the gallbladder in April 2012, both considered to be normal. The examiner noted in March 2001, it was determined by a gastroenterologist that the Veteran is obese and was diagnosed with fatty liver. This diagnosis was again confirmed in October 2014. The examiner noted that the Veteran's levels have continued to decrease with medications for his cholesterol. In September 2020, the Veteran reported a normal range on his liver enzymes. The Veteran was afforded a VA examination in October 2020. The examiner diagnosed the Veteran with "fatty liver." The examiner noted that the varying degrees of elevated ALT over the years was "normalized" once the veteran began treatment for cholesterol following a "TIA" in 2015. The examiner noted that the elevation in ALT was "most likely due to fatty liver." No medication is required to control his liver disability. There are no signs or symptoms attributable to chronic or infectious liver disease. No diagnosis of hepatitis C or any incapacitating episodes due to the liver disability in the past 12 months. There is no cirrhosis. In the opinion, the examiner stated that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by his active-duty service. The examiner provided the rationale that there is no chronic diagnosis made for liver disorder manifested by chronic fatigue and that the objective examination is considered normal with symptoms being subjective. The examiner concluded that the elevated ALT readings was most likely caused by the Veteran's fatty liver. However, the Board finds the opinion to be inadequate. The examiner explains the cause of his elevated ALT readings but does not state whether the "fatty liver" he is currently diagnosed with was incurred in or caused by his active-duty service, specifically, as a result of his military occupational specialty (MOS) while working in the hazmat pharmacy, and whether this disability can cause functional impairment in the Veteran's earning capacity. As such, the Board finds a remand is necessary in order to obtain an addendum opinion. The matters are REMANDED for the following action: Forward the record and a copy of this remand to the examiner who conducted the October 2020 VA examination. If the examiner is unavailable, forward the records to a similarly situated examiner. If an additional examination is needed to respond, the examination should be scheduled. Following a review of the record, the examiner should provide an addendum opinion as to: Whether it is at least as likely as not (50 percent or greater probability) that the Veteran's "fatty liver" was incurred in or caused by his active-duty service (specifically, his MOS while working in the hazmat pharmacy), and if so, whether such condition results in functional impairment in the Veteran's earning capacity. Michael J. Skaltsounis Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. DeBoer, Associate 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.