Citation Nr: 21068302 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 17-10 948A DATE: November 9, 2021 ORDER Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is denied. Entitlement to an initial rating in excess of 10 percent for left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, is denied. Entitlement to a separate rating of 10 percent, but no higher, under Diagnostic Code 5284 for left foot spurring and arthritis is granted. Entitlement to an initial rating in excess of 10 percent for right foot hallux valgus, hallux rigidus, and hammer toes is denied. Entitlement to a separate rating of 10 percent, but no higher, under Diagnostic Code 5284 for right foot spurring and arthritis is granted. Entitlement to a rating in excess of 10 percent for reconstruction of the left ankle is denied. Entitlement to service connection for a right ear disability, other than tinnitus, is denied. Entitlement to service connection for diabetes mellitus, type II, is denied. Entitlement to service connection for a heart disability, claimed as residuals of a heart attack, is denied. Entitlement to service connection for hypertension is denied. REMANDED Entitlement to an increased rating for right total knee replacement, previously rated as degenerative joint disease of the right knee, rated as 10 percent prior to June 13, 2017, and as 30 percent disabling on and after August 1, 2018, is remanded. Entitlement to a compensable rating for fibrocystic breast disease is remanded. Entitlement to a higher initial rating for unspecified depressive disorder, rated as 0 percent disabling prior to January 5, 2017, and as 10 percent disabling on and after that date, is remanded. Entitlement to service connection for a skin disorder is remanded. Entitlement to service connection for a left ear disability, other than tinnitus, is remanded. Entitlement to service connection for a back disability is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's degenerative joint disease of the left knee has not manifested in flexion limited to 45 degrees or less or extension limited to 10 degrees or more, even when considering functional impairment due to factors such as pain, weakness, fatigability, incoordination, or pain on movement. 2. The Veteran's left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, have been assigned a 10 percent rating, which is the maximum schedular rating authorized under the applicable criteria, and the Veteran's hammer toes do not affect all toes. 3. The Veteran's left foot spurring and arthritis corresponds to foot injury of no more than moderate severity. 4. The Veteran's right foot hallux valgus, hallux rigidus, and hammer toes have been assigned a 10 percent rating, which is the maximum schedular rating authorized under the applicable criteria, and the Veteran's hammer toes do not affect all toes. 5. The Veteran's right foot spurring and arthritis corresponds to foot injury of no more than moderate severity. 6. The Veteran's reconstruction of the left ankle manifests in moderate, but not marked, limitation of motion, and it does not manifest in limitation of dorsiflexion to 5 degrees or less or to plantar flexion to 10 degrees plantar flexion or less. 7. Other than tinnitus, the Veteran does not have a current right ear disability, to include right ear hearing loss, for VA purposes 8. The Veteran did not exhibit diabetes mellitus, type II, in service or within one year after discharge from service; and diabetes mellitus, type II, is not otherwise shown to be associated with service. 9. The Veteran did not exhibit a heart disability in service or within one year after discharge from service; and a heart disability is not otherwise shown to be associated with service. 10. The Veteran did not exhibit hypertension in service or within one year after discharge from service; and hypertension is not otherwise shown to be associated with service. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5262. 2. The criteria for entitlement to an initial rating in excess of 10 percent for left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5280. 3. The criteria for entitlement to a separate rating of 10 percent, but no higher, for left foot spurring and arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5284. 4. The criteria for entitlement to an initial rating in excess of 10 percent for right foot hallux valgus, hallux rigidus, and hammer toes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5280. 5. The criteria for entitlement to a separate rating of 10 percent, but no higher, for right foot spurring and arthritis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.14, 4.71a, Diagnostic Code 5284. 6. The criteria for entitlement to a rating in excess of 10 percent for reconstruction of the left ankle have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1-4.14, 4.25, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 7. The criteria for entitlement to service connection for a right ear disability, other than tinnitus, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a), 3.385. 8. The criteria for entitlement to service connection for diabetes mellitus, type II, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 9. The criteria for entitlement to service connection for a heart disability, claimed as residuals of a heart attack, have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 10. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from December 1974 to July 1978 and from May 1980 to January 1995. These matters come before the Board of Veterans' Appeals (Board) on appeal from May 2012 and July 2014 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that a December 2019 Board decision granted entitlement to an initial 50 percent rating for migraine headaches. No portion of a headaches claim was remanded for additional development. The RO effectuated the Board's grant in a February 2020 rating decision and also listed this issue on a July 2021 supplemental statement of the case as if it were still on appeal. The Board notes that this claim is subject to a final Board adjudication, and the Board does not have jurisdiction to re-review it. It is therefore no longer on appeal. Increased Rating Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Disability ratings are determined by comparing a veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § Part 4. When there is a question as to which of two ratings to apply, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise the lower rating shall be assigned. 38 C.F.R. § 4.7. "Staged ratings," or different percentage evaluations for separate periods based on the facts found, may also be awarded. Fenderson v. West, 12 Vet. App. 119, 126-7 (1999); Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). Evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination, or pain on movement of a joint under 38 C.F.R. § 4.45. See generally DeLuca v. Brown, 8 Vet. App. 202 (1995). Pain must affect some aspect of "the normal working movements of the body" such as "excursion, strength, speed, coordination, and endurance," in order to constitute functional loss. Mitchell v. Shinseki, 25 Vet. App. 32, 38-43 (2011) (quoting 38 C.F.R. § 4.40). Actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). Estimates of additional functional impairment during flare-ups, if any, are also to be recorded, or an explanation with adequate rationale must be given as to why such estimates are not possible. Sharp v. Shulkin, 29 Vet. App. 26 (2017). 1. Entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is denied. Separate ratings may be assigned for limited knee motion in flexion (under Diagnostic Code 5260) and in extension (under Diagnostic Code 5261), as well as for instability (under Diagnostic Code 5257). VA Gen. Counsel. Prec 23-97 (July 1, 1997). A separate compensable rating may also be assigned for meniscal pathology under Diagnostic Code 5258 or 5259. Lyles v. Shulkin, 29 Vet. App. 107 (2017). Under Diagnostic Code 5260, a 0 percent (noncompensable) rating is assigned for leg flexion limited to 60 degrees. A 10 percent rating is assigned for leg flexion limited to 45 degrees. A 20 percent rating is assigned for leg flexion limited to 30 degrees. A maximum 30 percent rating is assigned for leg flexion limited to 15 degrees. Diagnostic Code 5261 provides a 0 percent rating for leg extension limited to 5 degrees. A 10 percent rating is warranted where extension is limited to 10 degrees. A 20 percent rating is warranted where extension is limited to 15 degrees. A 30 percent rating is warranted where extension is limited to 20 degrees. A 40 percent rating is warranted where extension is limited to 30 degrees. A 50 percent rating is warranted where extension is limited to 45 degrees. Under Diagnostic Code 5003, when limitation of motion is noncompensable, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion. Even in the absence of limitation of motion, actually painful, unstable, or malaligned joints due to healed injury are entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1 (2011). Joints are to be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if applicable, with the range of the opposite, undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 168 (2016). The Board notes that some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. There has been no substantive change to the criteria of Diagnostic Codes 5260 or 5261. Thus, a higher rating is not warranted under the new rating criteria. Under Diagnostic Code 5257, a rating of 10 percent is warranted when there is slight recurrent subluxation or lateral instability; a 20 percent rating is warranted when there is moderate recurrent subluxation or lateral instability; and a 30 percent rating is warranted when there is severe recurrent subluxation or lateral instability. Words such as "slight," "moderate," and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § 4.6. The Veteran is in receipt of a 10 percent rating for painful motion of the left knee that does not satisfy the criteria for entitlement to a compensable rating based on limitation of flexion or extension. The Board will look to determine whether a 10 percent rating based on limitation of motion is warranted for both limitation of flexion and limitation of extension. (The Board notes that painful flexion and extension that do not meet the limitation of motion criteria for a compensable rating cannot be awarded two separate 10 percent ratings. If both flexion and extension are limited to a compensable degree, however, separate 10 percent ratings may be warranted.) To receive a 10 percent rating based on limitation of motion, flexion must be limited to 45 degrees, or extension must be limited to 10 degrees. In the case at hand, the Veteran underwent VA knee examinations in April 2011, April 2014, December 2016, January 2020, and March 2021. The greatest level of limitation of motion was found in the April 2014 examination, which lists initial flexion limited to 100 degrees and extension limited to 0 degrees with no additional loss of range of motion on repetitive use. It was noted that the flare-ups impact the Veteran in that she "can walk a little bit then sit and rest," but there was no notation of additional limitation of range of motion, much less limitation to such a degree to satisfy the criteria for a rating of 10 percent for either flexion or extension. The examination reports note symptoms such as pain on motion. They also note limitations of function, such as limitation of standing. (See April 2011 VA examination report.) The range of motion measurements (on initial motion and after three repeated motions) and estimates (repeated use over time and on flare-up) take into account these symptoms in determining functional impairment. The evidence also reflects that the Veteran has worn knee braces and/or has used canes at various portions of the appeals period. (See, e.g., March 2021 VA knee and lower leg disability examination report.) The Veteran's use of an assistive device such as a cane and a brace is due to symptoms related to impairment of range of motion and thus is contemplated by the schedular rating criteria and the current rating. Cf. Spellers v. Wilkie, 30 Vet. App. 211, 218 (2018). The Board notes that a June 2018 opinion from Dr. H.S. provides a detailed description of the level of functional impairment due to the Veteran's knee disabilities. For example, it notes that the evidence reflects limitations in walking, standing, performing chores, exercising, squatting, stooping, bending, and rising from a seated position. The Board acknowledges the symptoms that have been described by the Veteran but notes that Dr. H.S. has not alleged that functional impairment leads to a decrease in range of motion of flexion to 45 degrees or of extension to 10 degrees. In light of the above, the Board finds that an increased rating based on limitation of motion is not warranted. Specifically, the Board finds that the criteria for entitlement to compensable ratings based on limitation of flexion and limitation of extension are not met, as flexion is not limited to 45 degrees and extension is not limited to 10 degrees during any portion of the appeals period. Given the above, the record does not demonstrate the even greater limitations of flexion and extension (to 30 degrees and 15 degrees, respectively) to warrant a 20 percent rating under Diagnostic Code 5260 or 5261. The Board will next consider whether a separate or higher rating is warranted based on another diagnostic code. The Board notes that all of the examination reports expressly note no instability. Therefore, entitlement to a separate rating is not warranted under Diagnostic Code 5257. In the absence of a left knee meniscal pathology, a separate rating under Diagnostic Code 5258 or 5259 is not warranted. In the absence of ankylosis and impairment of the tibia and fibula, entitlement to a higher rating under Diagnostic Codes 5256 and 5262 is not warranted. Because a rating in excess of 10 percent is not available for genu recurvatum, the Board need not consider whether a rating is warranted under Diagnostic Code 5263. In short, the Board finds that entitlement to a rating in excess of 10 percent for degenerative joint disease of the left knee is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Entitlement to an initial rating in excess of 10 percent for left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, is denied. 3. Entitlement to a separate rating of 10 percent, but no higher, for left foot spurring and arthritis is granted. 4. Entitlement to an initial rating in excess of 10 percent for right foot hallux valgus, hallux rigidus, and hammer toes is denied. 5. Entitlement to a separate rating of 10 percent, but no higher, for right foot spurring and arthritis is granted. Service connection is in effect for left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, associated with reconstruction of left ankle. A rating of 10 percent is assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5280, for hallux valgus. Service connection is also in effect for any right foot condition to include hallux valgus, hallux rigidus, and hammer toes associated with reconstruction of left ankle. A rating of 10 percent is assigned under 38 C.F.R. § 4.71a, Diagnostic Code 5280, for hallux valgus. Disabilities of the feet are compensated under Diagnostic Codes 5269 through 5284. (The rating criteria of 38 C.F.R. § 4.71a were recently changed, effective February 7, 2021. In relevant part, these changes add Diagnostic Code 5269 for plantar fasciitis. However, the Veteran in the case at hand does not have plantar fasciitis, and this diagnostic code need not be further discussed.) In the absence of acquired flatfoot, a separate rating is not warranted under Diagnostic Code 5276. In the absence of bilateral weak foot, a separate rating is not warranted under Diagnostic Code 5277. In the absence of acquired claw foot (pes cavus), a separate rating is not warranted under Diagnostic Code 5278. In the absence of metatarsalgia, anterior (Morton's disease), a separate rating is not warranted under Diagnostic Code 5279. Maximum 10 percent ratings are already in effect for hallux valgus for each foot. Therefore a higher rating is not warranted under Diagnostic Code 5280. Diagnostic Code 5281 directs that hallux rigidus be rated as hallux valgus, severe, under Diagnostic Code 5280. The Veteran is already in receipt of 10 percent ratings for each foot under Diagnostic Code 5280. Therefore, a higher rating for hallux rigidus is not warranted. The evidence of record reflects that the Veteran has hammer toes on both feet. Specifically, the April 2014 VA foot conditions examination report notes hammer toes on the second through fourth toes of the left foot. The January 2020 VA foot conditions examination report notes hammer toes on the second through fourth toes of both feet. This evidence reflects that not all of the Veteran's toes are affected. Because all toes on one foot must be affected to warrant a compensable rating for hammer toes under Diagnostic Code 5282, and because this criterion is not satisfied for either foot, a compensable rating is not warranted for either foot under Diagnostic Code 5282. In the absence of malunion or nonunion of tarsal or metatarsal bones, a separate rating is not warranted under Diagnostic Code 5283. Finally, the Board will address whether a separate rating is warranted under Diagnostic Code 5284, which evaluates other foot injuries. This diagnostic code provides a 10 percent rating for moderate disability, a 20 percent rating for moderately severe disability, and a 30 percent rating for severe disability. A 40 percent rating is to be assigned with actual loss of use of the foot. In addition to the above conditions, the April 2014 VA examination report notes that the Veteran has bilateral degenerative arthritis. She reported that she has severe foot pain and can only walk for a little while before she has to sit and rest. It was reported that she has pain on use of the feet and pain is accentuated on manipulation of the feet. There is also swelling on use and tenderness on the plantar surfaces. There was pain on physical examination, and this pain contributed to functional loss. It was noted that her left foot had less movement than normal, pain on movement, swelling, and deformity. It was noted that both feet have pain on weight-bearing, disturbance of locomotion, interference with standing, and lack of endurance. There was not functional impairment such that either foot would be equally served by an amputation with prosthesis. A radiology report from the April 2014 examination notes that the right foot showed mild degenerative joint disease of the first metatarsophalangeal joint and a "plantar bony spur of the calcaneus." The December 2016 VA examination report notes bilateral degenerative arthritis. A radiology report from the December 2016 VA examination notes that the left foot showed "Mild to moderate degenerative changes at the first metatarsophalangeal joint," and that the imaging was "Stable [in] appearance when compared to the exam of 9/9/2015." Among pertinent findings, the examiner noted that the Veteran has "bilateral plantar callosities, more on left foot especially surrounding 5th toe and great toe on each foot." It was noted that she also has decreased active and passive movement of the left foot with dorsiflexion and plantar flexion, with both weight and non-weight bearing assessments." It was also noted that her foot and ankle condition affects her ability to perform basic activities of daily living without difficulty, specifically noting that it "affects her ability to perform personal hygiene and ambulate without pain or impairment." She also "cannot perform tasks that require prolonged standing or sitting, or any tasks that require crawling or stooping." The examiner determined that the Veteran's left and right foot disabilities have increased in severity since her last examination. The January 2020 VA foot conditions examination report focuses on the right foot. It notes right foot functional impairment on walking, standing, or sitting for too long. The examiner stated that the Veteran has foot injuries or other foot conditions not already described, and indicated that the disability level of the right side is of moderate severity. It was noted that the foot condition chronically compromises weight bearing. It was noted that pain on weight-bearing, swelling, and interference with standing contribute to disability. Functional loss due to pain/tenderness with pressure was noted to limit daily activities. The March 2021 VA foot conditions examination report focuses on the left foot. It notes a diagnosis of spur under "Foot injury(ies)." She experiences severe flare-ups when standing for too long. The examiner stated that the Veteran has foot injuries or other foot conditions not already described, and indicated that the disability level of the left side is of moderate severity. It was noted that the foot condition chronically compromises weight bearing. It was noted that the Veteran had pain on physical examination and that she also experiences interference with standing. Functional loss due to pain/tenderness with pressure was noted to limit daily activities. There was pain on active motion, passive motion, and weight bearing. Calcaneal spur was noted on diagnostic testing. Based on the above, the Board finds that separate ratings of 10 percent, but no higher, are warranted for foot injuries under Diagnostic Code 5284. These ratings are based on the findings of the January 2020 and March 2021 VA examination reports showing the existence of arthritis and calcaneal spurs that are not compensated under Diagnostic Code 5280. Given that the evidence does not reflect that these diagnoses developed during the course of the appeals period, but existed throughout, the Board will assign this rating throughout the appeals period. The Board finds that ratings of 10 percent, reflecting moderate disability level, are most appropriate. The Board notes that the VA examiners estimated these disabilities as being of moderate severity, and the Board finds that the Veteran's reported symptoms and functional impairment, as well as the findings on physical examination, are most accurately characterized as moderate. Specifically, the Board notes that the Veteran's arthritis and spurring interfere with her ability to perform certain activities of daily living. However, the evidence of record makes clear that much of this interference is caused by a combination of impairments from her knees and left ankle disabilities. Given the moderate nature of her foot arthritis and spurring specifically, the Board finds it appropriate to assess these disabilities as being of no more than moderate severity. In short, the Board finds that entitlement to ratings in excess of 10 percent are not warranted for her left foot hallux rigidus, hallux valgus, and hammer toes status post bunionectomy with screw fixation, with toes 2-4 arthroplasties and fifth plantar metatarsal head condylectomy, and her right foot hallux valgus, hallux rigidus, and hammer toes under Diagnostic Code 5280. To this extent, the claims are denied. The Board also finds that separate ratings of 10 percent, but no higher, are warranted for arthritis and spurring of her left and right feet under Diagnostic Code 5284. To this extent, the claims are granted. To the extent that the Veteran seeks ratings that are even higher than those that are reflected above, the Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the assignment of even higher ratings, the claims are not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, entitlement to ratings in excess of those that are assigned above must be denied. 6. Entitlement to a rating in excess of 10 percent for reconstruction of the left ankle is denied. Some of the rating criteria under 38 C.F.R. § 4.71a have recently changed, effective February 7, 2021. Prior to that date, the disability at issue will be considered under the criteria that were in effect at that time. On and after that date, claims will be considered under both old and new rating criteria, and the criteria that is more favorable to the Veteran will be applied. Prior to February 7, 2021, pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5271, moderate limitation of motion of the ankle is evaluated at 10 percent and marked limitation of motion of the ankle is evaluated at 20 percent. The Board notes that terms such as "moderate" and "marked" were not previously defined in the Rating Schedule. However, "moderate" is defined as "of average or medium quality, amount, scope, range, etc." See Webster's New World Dictionary, Third College Edition (1988) at 871. The Board also notes that beginning February 7, 2021, Diagnostic Code 5271 was revised to clarify that a moderate limitation of motion of the ankle was less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, and a marked limitation of motion of the ankle was less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. For reference full range of motion of the ankle is from 0 to 45 degrees plantar flexion and from 0 to 20 degrees dorsiflexion. 38 C.F.R. § 4.71a, Plate II. The greatest limitation of motion of the ankle appears in the April 2014 VA examination report. This report notes plantar flexion on initial testing to 25 degrees with objective evidence of painful motion beginning at 25 degrees. Dorsiflexion on initial testing was to 10 degrees with objective evidence of painful motion beginning at 10 degrees. There was no additional loss of range of motion following three repetitions. Functional impairment was due to less movement than normal and pain on movement. There was localized tenderness or pain on palpation of joints/soft tissue. There was no ankylosis of the ankle, subtalar, and/or tarsal joints. While the examination reports from that period do not regularly provide estimates of any additional impairment on repetitive use over time or during flare-ups, subsequent examinations do not report estimates of a greater degree of impairment on repetitive use over time or during flare-ups. The record reflects that the Veteran has reported several symptoms in connection with her left ankle disability. She has noted decreased range of motion, pain, and swelling. (See April 2014 VA ankle conditions examination report.) The Board finds that the above evidence reflects moderate rather than marked limitation of motion. The Board notes that the above evidence reflects dorsiflexion limited to less than half of normal dorsiflexion and plantar flexion no more than half normal plantar flexion, even when taking into account functional loss due to factors such as pain, weakness, fatigability, incoordination, or pain on movement. It also takes into consideration impairment on flare-ups and with repetitive use to the extent that such evidence is available. The Board finds that the impairment of the left ankle itself is best described as "moderate" and does not rise to the level of "marked" limitation of motion. Therefore, the Board finds that entitlement to a rating in excess of 10 percent is not warranted under the old rating criteria. The Board further finds that a rating in excess of 10 percent is not warranted under the revised rating criteria. Under the revised rating criteria, a moderate limitation of motion of the ankle is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, and a marked limitation of motion of the ankle is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. The Board notes that the Veteran's impairments, as described above, fit squarely within the criteria for the 10 percent rating criteria. Therefore, a rating in excess of 10 percent is not warranted under either the old or the new rating criteria. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, or nexus, between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for listed chronic diseases, such as sensorineural hearing loss, diabetes mellitus, cardiovascular-renal disease, and hypertension, if such were shown as chronic in service; manifested to a compensable degree within a presumptive period (usually one year) after separation from service; or were noted in service with continuity of symptomatology since service. 38 U.S.C. §§ 1112, 1113; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). 7. Entitlement to service connection for a right ear disability, other than tinnitus, is denied. Service connection for impaired hearing shall only be established when hearing status as determined by audiometric testing meets specified puretone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels) over a range of frequencies (in Hertz). Hensley v. Brown, 5 Vet. App. 155, 158 (1993). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran's service treatment records reflect that she reported experiencing bilateral ear pain in September 1980, and the impression of history of recurrent sore throat was given. She reported a history of, or current, ear nose, or throat trouble on an October 1989 medical history report, but she specified that this complaint was for a cold thyroid nodule. The Board notes that the Veteran's service treatment records reflect that she neither complained of nor sought treatment for symptoms associated with her right ear during service. Post-service medical records reflect that she has not been diagnosed with a right ear disability. She underwent VA hearing loss examinations in connection with this claim in July 2014 and February 2020. The July 2014 right ear audiograms reads as follows: HERTZ 500 1000 2000 3000 4000 Right 15 5 5 5 10 The speech discrimination score was 100 percent. The February 2020 right ear audiograms reads as follows: HERTZ 500 1000 2000 3000 4000 Right 15 5 10 5 20 Her right ear speech discrimination score was 100 percent. There are no other audiology reports of record, and the Veteran has not otherwise been diagnosed with right ear hearing loss disability for VA purposes. Furthermore, no right ear disability has otherwise been diagnosed. The July 2014 VA ear conditions examination report diagnoses a very small pustule of the left auricle, but it makes no right ear disability diagnosis. A January 2020 VA ear conditions examination report found that no right ear disability diagnosis was warranted. The Board finds these opinions to be highly probative, as they were authored by individuals (a nurse practitioner and an audiologist) who possess the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). These opinions are based on review of the record and interview and examination of the Veteran. The Board notes that the VA treatment records do not contain a diagnosis for a right ear disability. The only remaining contrary opinion comes from the Veteran herself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim, the diagnosis of right ear disability, to include hearing loss of VA purposes, are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. Watson v. Brown, 4 Vet. App. 309, 314 (1993); see also Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). As such, entitlement to service connection for a right ear disability is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 8. Entitlement to service connection for diabetes mellitus, type II, is denied. The Veteran's service treatment records reflect that she was neither diagnosed with nor suspected to have diabetes during service. Within a few months prior to her separation from service, an August 1995 service treatment record affirmatively states that the Veteran does not have diabetes. The Veteran repeatedly denied having diabetes during service, including on numerous dental health questionnaires. Post-service medical records do not reflect that the Veteran was diagnosed with diabetes mellitus within one year of separation from service. A March 2003 VA medical record notes that the Veteran is not diabetic. A December 2007 VA medical record notes that the Veteran's "fbs and hgbalc are elevated and she is looking like a new diabetic." A January 2008 VA medical record notes that the Veteran is a diagnosed diabetic. A February 2010 private medical record notes that the Veteran has a history of diabetes since 2008. In short, the competent evidence of record reflects that the Veteran was diagnosed with diabetes approximately 12 years following her separation from service. The Veteran has provided no medical evidence that links her diabetes to service. Therefore, entitlement to service connection for diabetes mellitus is denied on a direct basis and on a presumptive basis based on chronic disability. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 9. Entitlement to service connection for a heart disability, claimed as residuals of a heart attack, is denied. The Veteran's service treatment records reflect that she was neither diagnosed with nor suspected to have a heart condition during service. Chest radiology reports dated in July 1995 and August 1995 note that the Veteran's heart was normal in size. The Veteran repeatedly denied having heart problems or angina, heart murmur, mitral valve prolapse congenital heart lesions, heart surgery, prosthetic heart valve(s), or a pacemaker during service, including on numerous dental health questionnaires towards the end of her service. Post-service medical records do not reflect that the Veteran was diagnosed with a heart condition within one year of separation from service. Post-service treatment records reflect that the Veteran suffered a myocardial infarction in February 2003, at which time she underwent a left heart catheterization, left ventriculography, and coronary arteriography. This is the earliest evidence of a heart condition. The Veteran underwent a VA heart conditions examination in January 2020. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed coronary artery disease and status post stent placement. The examiner opined that it was less likely as not that the claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale is that "In review of medical records, no information found regarding condition till after service." The Board finds this opinion to be highly probative, as it was authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and interview and examination of the Veteran. The rationale cites to the facts of the Veteran's case. In short, the competent evidence of record reflects that the Veteran's coronary artery disease status post stent placement was found approximately eight years following her separation from service. The Veteran has provided no medical evidence of a heart disability in service or within one year of separation from service or that otherwise links her heart disability to service. Therefore, entitlement to service connection for a heart disability is denied on a direct basis and on a presumptive basis based on chronic disability. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 10. Entitlement to service connection for hypertension is denied. For VA purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm. or greater with a diastolic blood pressure of less than 90mm. 38 C.F.R. § 4.104, Diagnostic Code 7101 (Note 1). Review of the Veteran's service treatment records shows no diagnosis of hypertension and reflects that she consistently and exclusively denied a history of, or current, hypertension. The record reflects that her blood pressure was taken many times during service, and none of the readings satisfied the criteria for hypertension, including those taken within months of her final separation from service. The Veteran repeatedly denied having hypertension during service, including on numerous dental health questionnaires. Post-service medical records do not reflect that the Veteran was diagnosed with hypertension within one year of separation from service. The earliest indication of hypertension of record appears in a February 2003 private medical record, from the Veteran's heart attack, noting an impression of "[s]ystemic hypertension." The Veteran underwent a VA hypertension examination in January 2020. The examiner diagnosed hypertension. The examiner opined that it was less likely as not that the claimed condition was incurred in or caused by the claimed in-service injury, event, or illness. The examiner's rationale is that "In review of medical records, veteran was not seen w/ HTN till after service." The Board finds this opinion to be highly probative, as it was authored by a physician who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and interview and examination of the Veteran. The rationale cites to the facts of the Veteran's case. In short, the competent evidence of record reflects that the Veteran's hypertension was found several years following her separation from service. The Veteran has provided no medical evidence of hypertension in service or within one year of separation from service or that otherwise links her hypertension to service. Therefore, entitlement to service connection for hypertension is denied on a direct basis and on a presumptive basis based on chronic disability. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to an increased rating for right total knee replacement, previously rated as degenerative joint disease of the right knee, rated as 10 percent prior to June 13, 2017, and as 30 percent disabling on and after August 1, 2018, is remanded. The record reflects that the Veteran underwent a right knee arthroscopy with partial meniscectomy at a VA Medical Center on October 14, 2014. A post-operative note from that date notes that a prosthetics order was placed. A VA medical record from two weeks later notes that she was working on range of motion and is ambulating with a cane and full weightbearing on her right leg. It also notes that the Veteran was encouraged to work on range of motion and progressive ambulation, and was encouraged to add quadriceps strengthening exercises to improve leg strength. The Board notes that the issue of entitlement to a temporary total rating based on the need for convalescence under 38 C.F.R. § 4.30 has not been adjudicated and finds that a remand is necessary in order to adjudicate this claim in the first instance. 2. Entitlement to a compensable rating for fibrocystic breast disease is remanded. The Veteran's fibrocystic breast disease is rated under 38 C.F.R. § 4.116, Diagnostic Code 7628-7805. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 4.27. In this case, Diagnostic Code 7628 pertains to benign neoplasms of the gynecological system or breast and rates according to impairment in function of the urinary or gynecological systems, or skin. 38 C.F.R. § 4.117, Diagnostic Code 7805, applies to scars. The Veteran underwent a VA examination in connection with this claim in July 2014. It was noted that she has benign neoplasms of both breasts. It was noted that she has undergone biopsies in both breasts. She reported that she "can feel the lumps in my left breast and sometimes sharp pains shoot in my left breast." The Board notes that the Veteran's disability has been rated as noncompensable based on a determination that the scars themselves are not painful. The Board further notes that the cause of the pain in the Veteran's left breast has not been determined. Therefore, the Board finds it necessary to remand this claim so that the Veteran may undergo a new examination and an opinion may be obtained with respect to the cause of her breast pain. 3. Entitlement to a higher initial rating for unspecified depressive disorder, rated as 0 percent disabling prior to January 5, 2017, and as 10 percent disabling on and after that date, is remanded. The Veteran last underwent a VA examination in connection with this claim in January 2017. Following this examination, the Veteran's accredited representative submitted an April 2018 opinion from Dr. H.H-G. indicating a possible deterioration in the Veteran's psychiatric functioning. Given this opinion, and given the amount of time that has elapsed since the Veteran's last psychiatric examination, the Board finds it appropriate to remand this claim for a new VA examination. 4. Entitlement to service connection for a skin disorder is remanded. The service treatment records reflect that the Veteran sought treatment for rashes on her back, right hip, and near her vagina in July 1980. It was noted that the rash had started shortly following new medications and it was noted that the Veteran may have had an allergic reaction. The Veteran underwent a VA examination in connection with this claim in February 2020. Based on review of the record and interview and examination of the Veteran, the VA examiner determined that the Veteran did not have a current skin condition. The examiner therefore provided a negative etiology opinion. The first element of a service connection claim, the presence of a current disability, is satisfied if a disability is diagnosed at any point since the filing of the claim or prior but proximate 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 the case at hand, a September 2015 VA medical record notes an impression of acne, mild; Acanthosis Nigricans bilateral forehead; and idiopathic guttate hypomelanosis. A remand is necessary to obtain an etiology opinion to determine whether a diagnosis of any of these disabilities is related to service. 5. Entitlement to service connection for a left ear disability, other than tinnitus, is remanded. The Veteran's service treatment records reflect that she reported experiencing bilateral ear pain in September 1980, and the impression of history of recurrent sore throat was given. An August 1981 service treatment record reflects that she sought treatment for viral syndrome and serous otitis media. She reported a history of, or current, ear nose, or throat trouble on an October 1989 medical history report, but she specified that this complaint was for a cold thyroid nodule. Otherwise, her service treatment records reflect that she neither complained of nor sought treatment for difficulties associated with her left ear. The July 2014 and February 2020 VA hearing loss and tinnitus examination reports reflect that the Veteran's left ear hearing does not satisfy the criteria to be considered a left ear hearing loss disability for VA purposes. 38 C.F.R. § 3.385. However, the July 2014 VA ear conditions examination report diagnoses a very small pustule of the left auricle. As noted above, the first element of a service connection claim, the presence of a current disability, is satisfied if a disability is diagnosed at any point since the filing of the claim or prior but proximate to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). A remand is necessary to obtain an etiology opinion to determine whether a diagnosis of a pustule of the left auricle is related to service. 6. Entitlement to service connection for a back disability is remanded. The Veteran underwent VA back conditions examinations in January 2020 and June 2011. Based on review of the record and interview, examination, and diagnostic testing of the Veteran, the January 2020 VA examiner diagnosed degenerative arthritis of the spine and bulging disc. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale featured the misconception that the Veteran's service treatment records do not show back complaints or treatment in service. The Board notes, however, that a July 1984 record notes that the Veteran sought treatment for a lumbar strain. It was noted that the Veteran had been doing exercises the day before and that her back had popped. VA thus sought a new examination and opinion that takes into account the fact that the July 1984 record was, in fact, a service treatment record. Based on review of the record and interview, examination, and diagnostic testing of the Veteran, the June 2021 VA examiner diagnosed degenerative arthritis and spondylolisthesis. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale again featured the misconception that the Veteran's service treatment records do not show back complaints or treatment in service. The examiner noted that "Records showed back pain in 1984(not in service)." As noted above, however, this record is, in fact, a service treatment record. Therefore, a remand is required to obtain an addendum opinion that addresses the presence of treatment for a lumbar strain in service. 7. Entitlement to a TDIU is remanded. The Board will defer consideration of this claim, as it is inextricably intertwined with the claims that are being remanded above. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran's records were last obtained. 2. Schedule the Veteran for a VA examination to determine the current severity of her fibrocystic breast disease. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. In particular, the examiner should provide an opinion as to the likely cause of the Veteran's reported left breast pain. Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 3. Schedule the Veteran for a VA examination to determine the current severity of her unspecified depressive disorder. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The Veteran's claims folder must be reviewed by the examiner in conjunction with the examination. The examiner should identify and completely describe all current symptomatology. 4. Obtain an addendum opinion to the February 2020 VA skin diseases examination report from a qualified examiner with respect to whether the Veteran has a current skin disability that is at least as likely as not (a 50 percent probability or greater) related to service. The Veteran's claims folder must be reviewed by the examiner, and review of the claims file must be noted in the examination report. In offering this opinion, the examiner must discuss the September 2015 VA medical record that notes an impression of acne, mild; Acanthosis Nigricans bilateral forehead; and idiopathic guttate hypomelanosis. This impression is considered to be a current diagnosis for purposes of establishing service connection. Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 5. Obtain an addendum opinion to the July 2014 VA ear conditions examination report from a qualified examiner with respect to whether the very small pustule of the left auricle that was diagnosed in July 2014 is at least as likely as not (a 50 percent probability or greater) related to service. The Veteran's claims folder must be reviewed by the examiner, and review of the claims file must be noted in the examination report. The impression of very small pustule of the left auricle is considered to be a current diagnosis for purposes of establishing service connection. In offering this opinion, the examiner must discuss the September 1980 service treatment record that lists complaints of bilateral ear pain. The examiner must also discuss the August 1981 service treatment record reflecting that the Veteran sought treatment for viral syndrome and serous otitis media. Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 6. Obtain an addendum opinion to the January 2020 and June 2011 VA back conditions examination reports from a qualified examiner with respect to whether the Veteran has a current back disability that is at least as likely as not (a 50 percent probability or greater) related to service. The January 2020 VA back conditions examination report diagnoses degenerative arthritis of the spine and bulging disc, and the June 2021 VA back conditions examination report diagnoses of degenerative arthritis and spondylolisthesis. The Veteran's claims folder must be reviewed by the examiner, and review of the claims file must be noted in the examination. In offering this opinion, the examiner must discuss the July 1984 service treatment record that notes that the Veteran sought treatment for a lumbar strain. It was noted that the Veteran had been doing exercises the day before and that her back had popped. (The Board notes that the prior two opinions, dated in January 2020 and June 2021, are based on the incorrect assumption that the July 1984 record was not a service treatment record. In fact, the July 1984 record noting treatment for a lumbar strain is a service treatment record.) Any opinion must contain a complete rationale that includes discussion of the facts of the case and pertinent medical principles. If the VA examiner is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 7. Following completion of the above, readjudicate the issues on appeal, to include the issue of entitlement to a temporary total rating for convalescence following October 14, 2014, right knee surgery and the issue of entitlement to a TDIU. If any requested benefit remains denied, furnish the Veteran and her representative with a supplemental statement of the case. The appropriate period should be allowed for response before the appeal is returned to the Board. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Elizabeth Jalley, 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.