Citation Nr: 21071200 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 17-46 702 DATE: November 30, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA) is denied. Entitlement to service connection for gout is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for a spine condition is denied. Entitlement to service connection for a left ankle condition is denied. Entitlement to service connection for a right ankle condition is denied. Entitlement to a disability rating of 30 percent, but not higher, from June 5, 2013, for a left knee condition is granted. Entitlement to a disability rating in excess of 30 percent from January 24, 2020, for a left knee condition is denied. Entitlement to a disability rating of 30 percent, but not higher, from June 5, 2013, for a right knee condition is granted. Entitlement to a disability rating in excess of 30 percent from January 24, 2020, for a right knee condition is denied. Entitlement to a disability rating in excess of 40 percent from February 19, 2021, for a right knee condition is denied. Entitlement to a disability rating in excess of 0 percent for left ear hearing loss is denied. Entitlement to an effective date prior to June 5, 2013, for service connection for tinnitus is denied. Entitlement to an effective date prior to June 5, 2013, for service connection for left ear hearing loss is denied. Entitlement to an effective date prior to June 5, 2013, for a left knee condition is denied. Entitlement to an effective date prior to June 5, 2013, for a right knee condition is denied. FINDINGS OF FACT 1. The Veteran's OSA was not incurred in or a result of his active-duty service. 2. The Veteran's gout was not incurred in or a result of his active-duty service. 3. The Veteran's hypertension was not incurred in or a result of his active-duty service. 4. The Veteran's spine condition was not incurred in or a result of his active-duty service. 5. The Veteran's left ankle condition was not incurred in or a result of his active-duty service. 6. The Veteran's right ankle condition was not incurred in or a result of his active-duty service. 7. From June 5, 2013, the Veteran's left knee condition was limited to 20 degrees of extension following repeated use over time. 8. From January 24, 2020, the Veteran's left knee condition was not limited to 30 degrees of extension. 9. From June 5, 2013, the Veteran's right knee condition was limited to 20 degrees of extension following repeated use over time. 10. From January 24, 2020, the Veteran's right knee condition was not limited to 30 degrees of extension. 11. From February 19, 2021, the Veteran's right knee condition was not limited to 45 degrees of extension. 12. The Veteran's left ear hearing loss has manifested as Levels II, IV, and VII throughout the rating period on appeal, while the Veteran's right ear hearing loss has manifested as Level I. 13. The Veteran's claim for service connection for tinnitus was filed July 2, 2014. 14. The Veteran's claim for service connection for left ear hearing loss was filed June 5, 2014. 15. The Veteran's claim for service connection for a left knee condition was filed June 5, 2014. 16. The Veteran's claim for service connection for a right knee condition was filed June 5, 2014. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for gout have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 3. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 4. The criteria for entitlement to service connection for a spine condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 5. The criteria for entitlement to service connection for a left ankle condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 6. The criteria for entitlement to service connection for a right ankle condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. 7. From June 5, 2013, the criteria for entitlement to a disability rating of 30 percent, but not higher, for a left knee condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 8. From January 24, 2020, the criteria for entitlement to a disability rating in excess of 30 percent for a left knee condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 9. From June 5, 2013, the criteria for entitlement to a disability rating of 30 percent, but not higher, for a right knee condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 10. From January 24, 2020, the criteria for entitlement to a disability rating in excess of 30 percent for a right knee condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 11. From February 19, 2021, the criteria for entitlement to a disability rating in excess of 40 percent for a right knee condition have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. § 4.71a, Diagnostic Code 5261. 12. The criteria for entitlement to a disability rating in excess of 0 percent for left ear hearing loss have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.385, 4.85, Diagnostic Code 6100. 13. The criteria for entitlement to an effective date prior to June 5, 2013, for service connection for tinnitus have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 14. The criteria for entitlement to an effective date prior to June 5, 2013, for service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 15. The criteria for entitlement to an effective date prior to June 5, 2013, for a left knee condition have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. 16. The criteria for entitlement to an effective date prior to June 5, 2013, for a right knee condition have not been met. 38 U.S.C. §§ 5107, 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1973 to January 1976. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of May 2015 and July 2017 issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Board previously remanded this case for additional development. See July 2019 Board Decision at 7 (remanding for Social Security Administration (SSA) records); see also id. at 8 (remanding for additional medical examinations); see also id. at 8-9 (remanding for issuance of statements of the case (SOC)). After reviewing the evidence of record, the Board finds that the RO has substantially fulfilled its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (providing that a remand confers upon the Veteran the right to substantial compliance with remand instructions). The Board briefly notes that the Veteran's appeal originally included the additional issues of service connection for a psychiatric condition and for headaches. See July 2019 Board Decision at 7-8. However, the record reflects that these claims were subsequently granted by the RO. See July 2020 Rating Decision; see also February 2021 Rating Decision (continuing initial disability ratings assigned). Accordingly, they are no longer before the Board. A claim for an increased disability rating for tinnitus was previously adjudicated by the Board and is likewise no longer on appeal. See July 2019 Board Decision at 7. The Board also notes that the Veteran has separately appealed the initial disability ratings assigned for his psychiatric condition and headaches, to specifically include entitlement to a total disability rating based on individual unemployability (TDIU), under the Veterans Appeals Improvement and Modernization Act of 2017 (VAIMA). See June 2021 VA Form 10182. Because the disability ratings associated with the Veteran's psychiatric condition and headaches are relevant to his potential entitlement to a TDIU, the Board finds that the evidence of record is not sufficiently developed to sustain adjudication of the Veteran's TDIU claim at this time. Accordingly, that claim will be adjudicated in the Veteran's appeal under the VAIMA. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (providing that issues may be inextricably intertwined where the outcome of one claim could have a significant impact upon the outcome of another). Finally, the Board notes that the Veteran's appeal originally included claims for increased disability ratings for bilateral hearing loss. See July 2019 Board Decision at 6. However, service connection for the Veteran's right ear hearing loss was subsequently severed by the RO, and the Veteran has not properly appealed this decision to the Board. See February 2020 Rating Decision. Accordingly, the Board has characterized the Veteran's increased rating claim for his left ear hearing loss as presented above. Service Connection Service connection generally requires the existence of a present disability, the in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 1. Entitlement to service connection for OSA. The Veteran's service treatment records (STR) do not reflect a diagnosis or treatment for OSA. See February 2015 STR. However, the Veteran's more recent medical treatment records indicate symptoms of sleep disturbances, which may be attributable to OSA. See February 2021 Medical Treatment Records at 76 (providing treatment note of June 2018 indicating "possible sleep apnea"); see also id. at 85 (providing treatment note of January 2018 indicating that the Veteran is "[also] at risk [for] sleep-related hypoventilation given his obesity"). It is unclear to the Board from the Veteran's medical records whether a sleep study to confirm a diagnosis of OSA was in fact conducted. See December 2019 Medical Treatment Records at 4 (providing message to Veteran of June 2019 indicating that "[when] you return... we can get you in touch with our sleep doctors/clinic"); cf. October 2021 Medical Treatment Records. The Veteran has not undergone a VA examination addressing this issue. "In disability compensation claims, [VA] must provide a VA medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service... and (3) an indication that the disability... may be associated with the veteran's service... but (4) insufficient competent medical evidence on file... to make a decision on the claim." McLendon v. Nicholson, 20 Vet. App. at 81. The third McLendon element "requires only that the evidence 'indicates' that there 'may' be a nexus between the two." Id. at 83. "This is a low threshold... [and includes] credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation." Id. The Veteran has offered no evidence, nor any argument beyond the bare assertion of entitlement to service connection for this condition, to support the conclusion that OSA was incurred in or a result of his active-duty service. The Board has not otherwise found such evidence in its review of the record. The Board has instead found evidence that the Veteran's symptoms of disturbed sleep are in fact already compensated as part of his service-connected psychiatric condition. See February 2020 VA Examination Report (Psychiatric) at 6 (noting "chronic sleep impairment"). The Board therefore concludes that the second and third Shedden factors, as well as the second and third McLendon factors, have not been met. Neither service connection for this condition nor remand for a VA examination is therefore warranted. 38 C.F.R. § 3.303. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against the Veteran's claim. 38 U.S.C. § 5107. 2. Entitlement to service connection for gout and hypertension. The Veteran's medical treatment records indicate that the Veteran has been diagnosed with gout and hypertension, though such conditions do not appear in his STR. See December 2019 Medical Treatment Records at 19 (providing January 2019 treatment note "[following up] after ER visit for gout attack... has colchicine, feels things are getting better"); see also id. at 6 (providing June 2019 diagnosis of hypertension, among other conditions); see also September 2021 Medical Treatment Records at 1 (diagnosing gout, among other conditions, following contemporaneous discharge from hospital); cf. February 2015 STR. The Veteran has also not undergone VA examinations specifically addressing these claims. The criteria for determining whether a VA examination is warranted are discussed above. See McLendon, 20 Vet. App. at 81. Because the Veteran has again provided no evidence that these conditions were incurred in or a result of his active-duty service, and the Board has not otherwise found such evidence in the record, the Board likewise finds that the second and third Shedden and McLendon factors have not been met. The Board has also found no evidence in the record to suggest that the Veteran's hypertension manifested within one year of his active-duty service, which would allow service connection for that condition on a presumptive basis. See 38 C.F.R. § 3.309(a) (listing conditions for which service connection is available on this basis); cf. February 2017 Medical Treatment Records at 151 (providing July 2006 treatment note observing "[no] prior [history] of heart disease [or] hypertension"). Neither service connection for these conditions nor remand for a VA examination is therefore warranted. 38 C.F.R. § 3.303. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against the Veteran's claims. 38 U.S.C. § 5107. 3. Entitlement to service connection for spine and bilateral ankle conditions. The Board notes that the Veteran's STR reflect treatment for injuries to the back and left ankle. See February 2015 STR at 5-6; see also id. at 13. The Veteran previously underwent VA examinations addressing these issues in April 2017. The examiner opined in pertinent part as follows: [The Veteran's] left ankle strain is less likely than not incurred in or caused by a specific in-service illness, event, or injury. [The] Veteran reports he did not experience his current ankle problems until 2002. No records support a continuation. His current condition is ankle strain, which is a result of his obesity... [His] lumbar strain is less likely than not due to service. [He] reports he did not experience his current back problems until around 2002. His current condition is chronic lumbar strain. While he did experience back pain in service the lack of continuity of symptoms from 1976-2002 makes it less likely than not [that] his current back condition resulted from the back pains he had in service. See April 2017 VA Medical Opinion at 2 (emphasis added). The Board notes that evidence of a prolonged period without medical complaint can be considered along with all the other evidence of record. See Maxson v. Gober, 230 F.3d 1330 (2000). The Board also notes a statement from the Veteran specifically attributing each of his musculoskeletal conditions not to his active-duty service, but to his subsequent career as a civilian laborer: I have been working for Pacific Iron & Metals Company for 34 years... It's hard work mentally and physically. We did not have the equipment that we have today to do our jobs. In those days it was manpower... In the best of my knowledge I believe from all the lifting it causes my knees to buckle [and] ankles to sprain very easily and now even my back and shoulders are very sore. At this time I have to wear knee braces and ankle braces... [and] I have a hard time climbing stairs. See December 2019 SSA Records at 40; see also id. at 45 (reporting frequent lifting of weights in excess of 100 pounds). Based on the VA examination report discussed above, the Veteran's own statement attributing the cause of his musculoskeletal conditions to his post-service employment, and the absence of any other evidence in the record or argument submitted by the Veteran that these conditions were incurred in or a result of his active-duty service, the Board concludes that the third Shedden factor has not been met. The assignment of service connection for these conditions is therefore not warranted. 38 C.F.R. § 3.303. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against the Veteran's claims. 38 U.S.C. § 5107. Increased Ratings Disability evaluations are determined by comparing a Veteran's present symptomatology with criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for a higher rating. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3. The Veteran's entire history is reviewed when making disability rating decisions. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). However, where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Although a rating specialist is directed to review the recorded history of a disability in order to make a more accurate evaluation, the regulations do not give past medical reports precedence over current findings. See 38 C.F.R. § 4.2; Francisco v. Brown, 7 Vet. App. 55 (1994). When the appeal is from the initial rating assigned with the grant for service connection, "staged" ratings (for periods when varying degrees of disability are shown) may be assigned based on facts found. Fenderson v. West, 12 Vet. App. 119 (1999). Musculoskeletal Conditions In evaluating disabilities of the musculoskeletal system, consideration must be given to functional loss, including due to weakness and pain, affecting the normal working movements of the body in terms of excursion, strength, speed, coordination, and endurance. 38 C.F.R. § 4.40. With respect to disabilities of the joints, it must be considered whether there is less movement or more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement, as well as swelling, deformity, or atrophy of disuse. 38 C.F.R. § 4.45. These provisions thus require a determination of whether a higher rating may be assigned based on functional loss of the affected joint on repeated use as a result of the above factors, including during flare-ups of symptoms, beyond any limitation reflected on one-time measurements of range of motion. DeLuca v. Brown, 8 Vet. App. 202 (1995). However, a higher rating based on functional loss may not exceed the highest rating available under the applicable Diagnostic Code pertaining to range of motion. See Johnston v. Brown, 10 Vet. App. 80 (1997). In determining if a higher rating is warranted on this basis, pain alone does not constitute functional loss. Similarly, painful motion alone does not constitute limited motion for the purposes of rating under Diagnostic Codes pertaining to limitation of motion. However, pain may result in functional loss if it limits the ability to perform normal movements with normal excursion, strength, speed, coordination, or endurance as provided in 38 C.F.R. §§ 4.40 and 4.45. Functional loss due to pain is to be rated at the same level as functional loss caused by some other factor that actually limited motion. Mitchell v. Shinseki, 25 Vet. App. 32 (2011). 4. Entitlement to increased disability ratings for the Veteran's left knee condition. The Veteran's left knee condition is rated as 20 percent disabling from June 5, 2013, and as 30 percent disabling from January 24, 2020, under Diagnostic Code (DC) 5261. See October 2021 Rating Codesheet at 1-2. The applicable rating criteria provide that a disability rating of 20 percent is assigned where extension of the leg is limited to 15 degrees. See 38 C.F.R. § 4.71a, DC 5261. A disability rating of 30 percent is instead assigned where extension of the leg is limited to 20 degrees. Id. A disability rating of 40 percent is assigned where extension of the leg is limited to 30 degrees. Id. Finally, a disability rating of 50 percent is assigned where extension of the leg is limited to 45 degrees. Id. The Veteran has undergone VA examinations addressing this issue in April 2017, January 2020, and June 2021. The Veteran's medical records prior to the April 2017 VA examination reflect symptoms of bilateral knee pain, but support the inference that this pain is also attributable to the Veteran's gout. See February 2017 Medical Treatment Records at 63 (providing January 2014 treatment note observing bilateral knee pain and diagnosing arthritis based on x-ray results); see also id. at 43 (providing July 2014 fitting for knee braces); see also id. at 35 (providing January 2015 report of left knee pain and history of gout flares in the left knee); see also id. at 13 (providing May 2016 report of gout flare and resulting right knee pain); see also id. at 12 (noting contemporaneous full range of motion with mild pain on motion of right knee). These Board has otherwise found no evidence in these records to contradict the findings of the VA examiners as discussed below. The April 2017 VA examiner found extension of the leg limited to 15 degrees. See April 2017 VA Examination Report (Knee) at 5. The Board notes that this examination is not entirely adequate to support adjudication because it does not offer estimates as to additional functional loss experienced after repeated use over time or during flare-ups. See id. at 7-9; cf. Sharp v. Shulkin, 29 Vet. App. 26, 35 (2017) (providing that VA examiners are expected to provide estimates evaluating the additional degree of functional impairment experienced during flare-ups or after repeated use over time, and that direct observation under such conditions is not required). The January 2020 VA examiner found extension limited to 20 degrees. See February 2020 VA Examination Report (Knee) at 5; see also id. at 7-9 (estimating same limitation of extension during flare-ups or following repeated use over time). The February 2021 VA examiner also found extension limited to 20 degrees, with additional limitation to 25 degrees during flare-ups or following repeated use over time. See February 2021 VA Examination Report (Knee) at 7; see also id. at 9-11. None of the evidence of record supports the inference that the Veteran's left knee condition has diminished in severity over time. In other words, the Board has found no evidence to support the inference that the Veteran's functional impairment due to flare-ups or following repeated use over time was more severe at the time of the April 2017 VA examination than it was during the January 2020 or February 2021 examinations. Because the April 2017 VA examination is inadequate to fully support adjudication, the Board therefore finds it at least as likely as not that the degree of functional impairment estimated by the subsequent VA examiners is also applicable to the portion of the rating period on appeal prior to January 24, 2020. 38 U.S.C. § 5107; see also Sharp, 29 Vet. App. at 35. The assignment of a 30 percent disability rating for this condition from June 5, 2013 is therefore warranted. 38 C.F.R. § 4.71a, DC 5261. However, none of the VA examiners' findings support the inference that the Veteran's left knee condition has manifested as limitation of extension to 30 degrees, even during flare-ups or following repeated use over time. As discussed previously, the Board has not found evidence in the Veteran's medical treatment records to contradict the examiners' findings. The Veteran's assertions and supporting lay statements support the inference that he experiences symptoms of pain, but do not otherwise contradict the examiners' findings as to the functional limitations noted above. See April 2019 Correspondence at 1 (providing statement of Veteran's spouse observing "pain in his knees, which makes it painful for him to walk[,]" that he "wears knee braces and uses a cane[,]" and that "[it's] difficult for him to walk for long periods"); see also June 2021 VA Examination Report (Knee) at 3 (noting assertions of "[chronic] knee pain that is severe with weight bearing" and "inability to fully extend the knee"). The Board has considered whether additional disability ratings for separate knee conditions may be warranted. "[Evaluation] of a knee disability under DC 5257 [other impairment of the knee] or 5261 [limitation of extension] does not preclude, as a matter of law, separate evaluation of a meniscal disability of the same knee under DC 5258 [dislocated cartilage] or 5259 [removed cartilage]." Lyles v. Shulkin, 29 Vet. App. 107, 115 (2017); see also VAOPGCPREC 09-04 (providing for separately compensable disability ratings based on limitations of flexion and extension). However, the evidence of record does not support the inference that these additional disability ratings are applicable in this case. See April 2017 VA Examination Report (Knee) at 11-12 (finding no joint instability); see also id. at 13 (finding no meniscal conditions); see also February 2020 VA Examination Report (Knee) at 11-13 (same); see also February 2021 VA Examination Report (Knee) at 13-16 (same). Under DC 5260, a disability rating of 0 percent is assigned where flexion is limited to 60 degrees. See 38 C.F.R. § 4.71a, DC 5260. A disability rating of 10 percent is assigned where flexion is limited to 45 degrees. Id. A disability rating of 20 percent is instead assigned where flexion is limited to 30 degrees. Id. The VA examinations discussed above do not support the inference that a separate compensable rating based on limitation of flexion is warranted. See April 2017 VA Examination Report (Knee) at 5 (finding flexion limited to 110 degrees); see also February 2020 VA Examination Report (Knee) at 5 (finding flexion limited to 80 degrees); see also id. at 8-9 (estimating that repeated use over time or flare-ups would not further limit flexion); see also June 2021 VA Examination Report (Knee) at 7 (finding flexion limited to 90 degrees); see also id. at 10-11 (estimating that repeated use over time or flare-ups would further limit flexion to 85 degrees). The Board therefore concludes that a disability rating in excess of 30 percent from January 24, 2020, is not warranted. 38 C.F.R. § 4.71a, DC 5261. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence is against this portion of the Veteran's claim. 38 U.S.C. § 5107. 5. Entitlement to increased disability ratings for the Veteran's right knee condition. The Veteran's right knee condition is rated as 10 percent disabling from June 5, 2013, as 30 percent disabling from January 24, 2020, and as 40 percent disabling from February 19, 2021, under DC 5261. The applicable rating criteria are discussed in pertinent part above. See 38 C.F.R. § 4.71a, DC 5261. The April 2017 VA examiner found extension limited to 10 degrees. See April 2017 VA Examination Report (Knee) at 4. As discussed above, this examination is not fully adequate to support adjudication. See id. at 7-8; cf. Sharp, 29 Vet. App. at 35. The January 2020 VA examiner found extension limited to 15 degrees and estimated additional limitation to 20 degrees following repeated use over time or during flare-ups. See February 2020 VA Examination Report at 4; see also id. at 7-8. The February 2021 VA examiner found extension limited to 35 degrees. See February 2021 VA Examination Report at 5. This examiner also estimated additional limitation to 40 degrees following repeated use over time and to 30 degrees during flare-ups. Id. at 8-9. It is unclear to the Board why the examiner would estimate a degree of functional limitation during flare-ups less than that found during the examination itself in other words, why the limitation of extension under normal circumstances would be greater than that estimated to occur during a flare-up. The Board infers that this is at least as likely as not typographical error, and that the examiner intended to estimate limitation of extension to 40 degrees for both repeated use over time and during flare-ups. 38 U.S.C. § 5107. As discussed above, the progression of the Veteran's knee conditions and the inadequacy of the April 2017 examination report support the inference that it is at least as likely as not that the Veteran's right knee condition manifested with limitation of extension to 20 degrees following repeated use over time prior to January 24, 2020. 38 U.S.C. § 5107; see also Sharp, 29 Vet. App. at 35. The assignment of a 30 percent disability rating for this condition from June 5, 2013, is therefore warranted. 38 C.F.R. § 4.71a, DC 5261. However, the evidence of record does not support a disability rating in excess of 30 percent from January 24, 2020, nor a rating in excess of 40 percent from February 19, 2021. In reaching these conclusions, the Board again notes that the January 2020 and February 2021 examiners' findings are not contradicted by the Veteran's medical records or by the lay statements of record as discussed above. See February 2017 Medical Treatment Records, supra; see also September 2021 Medical Treatment Records at 66 (providing August 2021 treatment note observing "[range of motion] shy of full extension by about 20 degrees"). As discussed above, the evidence of record also does not support the assignment of additional disability ratings for joint instability, meniscal conditions, or limitation of flexion. See April 2017 VA Examination Report (Knee) at 4 (finding flexion limited to 90 degrees); see also id. at 11-13 (finding no joint instability or meniscal conditions); see also February 2020 VA Examination Report (Knee) at 4 (finding flexion limited to 100 degrees); see also id. at 7-8 (estimating further limitation to 80 degrees following repeated use over time or during flare-ups); see also id. at 11-13 (again finding no joint instability or meniscal conditions); see also February 2021 VA Examination Report (Knee) at 5 (finding flexion limited to 70 degrees); see also id. at 9-10 (estimating further limitation of flexion to 65 degrees following repeated use over time or during flare-ups); see also id. at 13-16 (again finding no joint instability or meniscal conditions). The Board therefore concludes that a disability rating in excess of 30 percent from January 24, 2020, and a disability rating in excess of 40 percent from February 19, 2021, for the Veteran's right knee condition are not warranted. 38 C.F.R. § 4.71a, DC 5261. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence of record is against the Veteran's claim. 38 U.S.C. § 5107. 6. Entitlement to a disability rating in excess of 0 percent for left ear hearing loss. For purposes of VA compensation, "impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 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 applicable rating criteria provide that the Veteran's hearing is measured using pure tone threshold averages, which are calculated using "the sum of the pure tone thresholds at 1000, 2000, 3000, and 4000 Hertz, divided by four." 38 C.F.R. § 4.85(d). These averages are combined with the Veteran's speech discrimination scores to create numeric designations for each ear. See 38 C.F.R. § 4.85(h), Table VI; see also § 4.85(a). These numeric designations are then combined to produce a disability rating. Id. at Table VII. The Veteran has undergone VA examinations addressing this issue in May 2015, April 2017, and June 2021. In pertinent part, these examiners found the following auditory thresholds: HERTZ 1000 2000 3000 4000 LEFT 30 25 75 90 See May 2015 VA Examination Report at 1; see also id. (calculating average auditory threshold of 55 decibels for the left ear); see also id. at 2 (finding speech recognition score of 88 percent for the left ear). HERTZ 1000 2000 3000 4000 LEFT 40 40 90 90 See April 2017 VA Examination Report at 2; see also id. (calculating average auditory threshold of 65 decibels for the left ear); see also id. at 3 (finding speech recognition score of 72 percent for the left ear). HERTZ 1000 2000 3000 4000 LEFT 55 60 100 100 See June 2021 VA Examination Report at 3; see also id. (calculating average auditory threshold of 78.75 decibels for the left ear); see also id. (finding speech recognition score of 60 percent for the left ear). These findings result in numerical designations of II, IV, and VII, respectively, for the Veteran's left ear. See 38 C.F.R. § 4.85(h), Table VI. Because the Veteran's right ear hearing loss is not service-connected, it is assigned a numerical designation of I for rating purposes. See 38 C.F.R. § 4.85(f). The combinations of II, IV, and VII with I each produce a noncompensable disability rating. See 38 C.F.R. § 4.85(h), Table VII. Certain patterns of hearing loss may be rated solely on the basis of pure tone thresholds in other words, without the use of speech discrimination scores. See 38 C.F.R. § 4.86 (providing that hearing impairment is considered "exceptional" where pure tone thresholds are 55 decibels or more at each of the four specified frequencies, or where the threshold is 30 decibels or more at 1000 Hertz and 70 decibels or more at 2000 Hertz). The Veteran's June 2021 VA examination results qualify for consideration on this alternative basis. However, as this produces the same numerical designations of VII for the Veteran's left ear and I for the Veteran's right ear, the ultimate result remains unchanged. See 38 C.F.R. § 4.85(h), Table VIA. The assignment of a disability rating in excess of 0 percent for the Veteran's left ear hearing loss is therefore not warranted. 38 C.F.R. § 4.85. The Board has considered the doctrine of reasonable doubt but concludes that it is not applicable because the balance of the evidence is against the Veteran's claim. 38 U.S.C. § 5107. 7. Entitlement to an effective date prior to June 5, 2013, for service connection for tinnitus, left ear hearing loss, and bilateral knee conditions. Generally, "the effective date of an evaluation and award of... compensation... based on an initial claim... will be the date of receipt of the claim or the date entitlement arose, whichever is later." See 38 C.F.R. § 3.400 (emphasis added); see also id. at (b)(2)(i). The Veteran's claims as to service connection for these issues were filed on June 5, 2014, and July 2, 2014. See June 2014 VA Form 27-0820 (informal claim asserting entitlement to service connection for bilateral hearing loss and bilateral knee conditions, among others); cf. July 2014 VA Form 21-526EZ at 1 (formal claim adding service connection for tinnitus, among other conditions). In the May 2015 rating decision on appeal, the RO granted service connection for hearing loss and tinnitus and assigned an effective date of July 2, 2013. See May 2015 Rating Decision at 1. The Veteran appealed the initial disability ratings and effective date assigned for these conditions. See July 2015 Notice of Disagreement (NOD) at 1. In the July 2017 rating decision on appeal, the RO subsequently found that this effective date had been erroneously assigned and revised the effective date to June 5, 2013. See July 2017 Rating Decision at 1-2; see also id. at 1 (granting service connection for bilateral knee conditions and assigning same effective date of June 5, 2013). The Veteran again appealed the disability ratings and effective dates assigned in this latter rating decision. See May 2018 NOD at 4. In its prior July 2019 decision, the Board remanded these issues for applicable Statements of the Case (SOC). See July 2019 Board Decision at 8-9; see also Manlincon v. West, 12 Vet. App. 238, 240-241 (1999). The record reflects that these SOC were subsequently issued in February 2020. The Veteran has not offered, nor has the Board otherwise found in the record, any argument or evidentiary basis whatsoever on which to support an earlier effective date than that already assigned by the July 2017 rating decision. See July 2015 Notice of Disagreement (NOD) at 1 (asserting, without supporting argument, entitlement to an earlier effective date for service connection for hearing loss and tinnitus); see also May 2018 NOD at 4 (same); see also September 2017 VA Form 9 (same); see also November 2019 NOD at 3 (same as to bilateral knee conditions). The assignment of an effective date earlier than that already assigned for these conditions is therefore not warranted. 38 C.F.R. § 3.400(b)(2). The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence is against the Veteran's claims. 38 U.S.C. § 5107. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Blore, 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.