Citation Nr: 21071618 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 18-23 635 DATE: November 30, 2021 ORDER Entitlement to service connection for a skin disorder (psoriasis), to include as secondary to service-connected major depressive disorder (MDD) and obsessive compulsive disorder (OCD) is denied. Entitlement to an increased disability rating greater than 10 percent for right knee degenerative joint disease (DJD) is denied. Entitlement to an increased disability rating greater than 10 percent for lumbar spine anterolisthesis with degenerative disc disease (DDD) is denied. FINDINGS OF FACT 1. The Veteran's psoriasis is not secondary to service-connected acquired psychiatric disorders (MDD, OCD),and is not otherwise related to an in-service injury or disease. 2. The Veteran's service-connected right knee DJD has been manifested by flexion no less than 120 degrees throughout the entire appeal period. 3. Across the entire appeal period, the Veteran's service-connected lumbar spine anterolisthesis with DDD was manifest by forward flexion no less than 70 degrees, with painful motion; the combined range of motion for the thoracolumbar spine was no less than 170 degrees. During this appeal period, the Veteran did not demonstrate forward flexion of the thoracolumbar spine between 30 degrees and 60 degrees nor a combined range of motion of the thoracolumbar spine that was 120 degrees or less. CONCLUSIONS OF LAW 1. The criteria for service connection for psoriasis due to service or service-connected acquired psychiatric disorders are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for a disability rating in excess of 10 percent for right knee DJD at any time across the appeal period are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71A, Diagnostic Code (DC) 5003-5260. 3. The criteria for a disability rating in excess of 10 percent lumbar spine anterolisthesis with DDD are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5003-5242. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 2003 to March 2009. These matters come to the Board of Veterans' Appeals (Board) from a May 2017 rating decision issued by the Agency of Original Jurisdiction (AOJ). In May 2021, the Board remanded the appeal for new VA examinations, which were obtained in June 2021. The Board finds that there has been substantial compliance with its directives and may now proceed with a decision. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for psoriasis, to include as secondary to service-connected acquired psychiatric disorder. The Veteran contends her diagnosed psoriasis is secondary to her service-connected acquired psychiatric disorders. See Transcript dated November 2020 at 21. The question for the Board is whether there is sufficient evidence to find that the Veteran's psoriasis is related to service or secondary to any other service-connected disability. For the reasons discussed below, the Board concludes that the evidence does not support a grant of service connection on a direct or secondary basis. Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Also, a Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Or for any increase in the severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(b). Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310. In order to prevail on a claim for benefits, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the "benefit of the doubt" when the evidence is approximately balanced. Id. at 53. Evidence on an issue is in "approximate balance" when the evidence for and against a finding on that issue is "almost exactly or nearly equal" or "too close to call." Ortiz v. Principi, 274 F.3d 1361, 1364-65 (Fed. Cir. 2001). Beginning with the Veteran's service, her service treatment records (STRs) show she did not report signs of a skin problem when she entered service. See September 25, 2003, Report of Medical History at 1. During service, she recognized the development of hives after consuming dairy products and reported to sick-call. See April 15, 2005, STR by C.G., MD. She did not visit sick-call again with complaints of skin problems. Neither did she report observing skin problems during her separation examination. See November 1, 2005, Report of Medical History at 1, 2; December 15, 2008, Report of Medical Examination; January 27, 2009, Report of Medical History at 1. In April 2017 the Veteran underwent VA examinations for her skin disorder and service-connected back and right knee disabilities. During the skin disorder examination, she reported psoriasis began two years before the examination (around 2015). When it was first observed, it was manifest by a scaling patch on the right side of her scalp. By the time of her April 2017 examination, she observed a dry patch on her elbow. See VA Disability Benefits Questionnaire (DBQ) at 2. The examiner diagnosed psoriasis and found it affects less than five percent of her total body area and less than five percent of total exposed areas (like hands, face, and neck). Id. at 1, 5. The examiner noted psoriasis is not associated with any other complications, to include debilitating and non-debilitating episodes. Id. at 4, 7. The April 2017 examiner opined the Veteran's psoriasis was not caused by a psychiatric disorder. The examiner explained psoriasis is a disorder of the immune system, which may be triggered by many factors, to include weather, nutritional deficiencies, and psychological stress. But the examiner emphasized that stress does not cause the disorder itself. See April 2017 VA Medical Opinion at 2. With regards to the examination of the Veteran's service-connected back disability, she reported her disability has remained about the same since its onset. See April 2017 VA DBQ at 3. She described the severity of her pain as a three to eight, out of 10 (with 10 being the most severe pain), which increased in severity when she sat for prolonged periods of time. She also reported flare-ups of increased pain. Numbness at the toes and pain radiating to both thighs was also reported. The Board notes the Veteran has already been assigned a separate rating for bilateral lower extremity radiculopathy (rated 10 percent from April 2010). The examiner found normal range of motion at the back, except on flare-ups. Initial range of motion testing for forward flexion was 0 to 90 degrees; for extension, 0 to 30 degrees. Range of motion testing for right, left lateral flexion and rotation was 0 to 30 degrees, amounting to a combined range of motion of 240 degrees. Repetitive use testing did not reveal any additional loss of motion. The examiner did not conduct tests of repeated use over time nor during flare-ups because the Veteran's was not examined under those circumstances. The examiner did not provide any opinion estimating additional functional loss due to flare-ups. Id. at 4, 5. The examiner did not find evidence of ankylosis, intervertebral disc syndrome (IVDS), guarding, or muscle spasms. Id. at 6. 9. 10. The examiner also found mild radiculopathy involving the sciatic nerve root. The Board notes the examination was found inadequate to evaluate the Veteran's back disability because the examiner did not address whether there was additional functional loss on flare-ups. See Transcript dated November 2020 at 6. Also, the Veteran reported the examiner did not use any tools to measure her range of motion. Id. Regarding the VA disability examination of her service-connected right knee DJD, she observed pain, clicking, and grinding at both knees. See April 2017 VA DBQ at 4. She described the severity of her pain as a two to six depending on her activities. Pain increases when walking, sitting too long, and going up and down stairs. She added that she observes flare-ups that require her to stay off her legs for a day. The examiner did not conduct testing of repeated use over time or on flare-ups. The examiner explained he could not perform those tests because the Veteran's was not examined under those circumstances. The examiner found evidence of joint instability at both knees but no other additional conditions, complications, or symptoms, due to the Veteran's right knee DJD, to include ankylosis. Id. at 10, 11, 15. The Veteran's VA Medical Center (VAMC) records show she reported complaints of psoriasis to M.V., MD, in June 2018. He noted conditions, like rashes and psoriasis, are common consequence of psychiatric disorders. Also, psoriasis is expected to worsen in times of stress. In November 2020, a Board hearing was conducted for the Veteran's entitlement claims. Beginning with her psoriasis claim, she reported her head had been itching for the last three years and, after researching her symptoms on the internet, she discovered the itchy skin may have to do with stress. She noticed her disorder shows when she is stressed. It disappears when she is not stressed. Her web-based research led her to believe her itchy scalp may have something to do with her service-connected psychiatric disorder. See Transcript at 17, 19. With regards to the Veteran's service-connected back disability, she testified she observes pain when she bends over, stands longer than 15 minutes, and sits longer than 30 minutes. Pain runs up her spine when she turns in certain directions. She also observes stiffness at her back when she sits and stands that limits her range of motion. As an example, she cannot bend over to touch her toes, pick things off the ground, and get dishes out of the dishwasher. Id. at 4. She added that, due to pain and stiffness, she cannot exercise, and has difficulty walking straight because she has cannot make sharp turns without observing pain. Id. at 5. She added that she believes back disability has worsened since her last VA disability examination. Id. at 6. Regarding the Veteran's service-connected right knee disability, she reported she observes severe pain, clicking noises, as well as swelling that leads to a sense of stiffness around her knee. Id. at 11. She reported it interferes with her ability to exercise and walk upstairs. If she tries to exercise, she observes daily flare-ups and, at times, her knee gives out. Id. at 16. So, she refrains from those types of activities. Id. at 13. To deal with her problems, she regularly wears a brace, which does not provide much relief. Id. at 13. Following a Board remand, the Veteran underwent more VA examinations in June 2021. During the June 2021 VA examination for the Veteran's psoriasis, she reiterated it began a few years ago. See VA DBQ at 2. It started an as itchy, scaling path on the right side of her scalp that has now moved to the left side of her scalp. The examiner diagnosed psoriasis and found it affects less than five percent of total body area and less than five percent of total exposed areas. Id. at 5. The examiner did not find any other complications due to psoriasis, to include debilitating and non-debilitating episodes. Id. at 7. Then, the examiner opined the Veteran's psoriasis is not secondary to her service-connected psychiatric disorders (MDD and OCD). The examiner acknowledged stress is believed to be a factor that can make psoriasis symptoms worsen, but a review of medical studies on the matter concluded there is not enough medical evidence to find a causal connection between psychological stress and the development of psoriasis. The examiner also indicated the long passage of time between the onset of the Veteran's service-connected psychiatric disorder and psoriasis is an additional factor that supports his opinion. See June 2021 VA Medical Opinion at 3, 5. The examiner also concluded the Veteran's psychiatric disorders did not aggravate her psoriasis. Id. at 4, 7. The examiner indicated he researched the matter and found there was not enough medical evidence to establish that the Veteran's particular psychiatric disorders contributed to the severity of her psoriasis. Due to these factors, the examiner disagreed with the favorable opinion by Dr. M.V. Id. at 5. Regarding the Veteran's June 2021 examination for her service-connected back DDD, she reported observing constant back pain. She described it as dull, aching, and non-radiating pain that worsens when she twists or bends. She observes flare-ups of increased pain that occur twice a week and last all day. Id. at 3. Generally, she could no longer wear heels due to her back pain. On flare-ups, she has difficulty bending. She also reported observing numbness and tingling at her right leg, but the examiner did not find radiculopathy. Id. at 11. The examiner found normal range of motion at the back, except on flare-ups. Id. at 4, 8. Initial range of motion testing for forward flexion was 0 to 90 degrees; for extension, 0 to 20 degrees. Range of motion testing for left lateral flexion and rotation was 0 to 30 degrees; for right lateral rotation and extension, it was 0 to 30 degrees. Id. at 4, 8. The combined range of motion was 230 degrees. Additional testing, to include passive range of motion, and repetitive use testing were not performed because it was the examiner's belief such testing would cause further injury. Id. at 5, 6. Although the examiner did not conduct the range of motion testing during a flare up, he provided an opinion based on the Veteran's statements describing functional loss due to pain in terms of range of motion. Forward flexion was 0 to 70 degrees; extension, 0 to 20 degrees; right lateral flexion and rotation was 0 to 20 degrees; left lateral flexion and rotation was 0 to 20 degrees. The combined range of motion for the spine was 170 degrees. Id. at 7-8. The examiner did not find evidence of ankylosis, IVDS, nor guarding or muscle spasms. There was evidence of localized tenderness, but the examiner noted tenderness did not result in abnormal gait or spinal contour. Id. at 8. Regarding the Veteran's June 2021 VA examination of her service-connected right knee DJD, she reported observing pain at the knee. She described a dull, achy pain that worsens with activity and temperature changes. See VA DBQ at 4. She also reported flare-ups of increased pain, swelling, that occur twice a week and last for several hours. Generally, her right knee disability prevents her from performing squatting movements and walking down stairs. On flare-ups she has greater difficulty climbing stairs and bending her knee. She reported instability and recalled her knee giving out on three occasions since leaving service (2009). Id. at 4. The examiner did not find recurrent subluxation or persistent instability. Id. at 13, 14. The examiner found limited flexion at the right knee with pain. Initial range of motion testing for flexion was 0 to 130; for flexion, it was 130 to 0 degrees. Repetitive use testing did not reveal additional loss of motion. Although the examiner did not conduct the range of motion testing during repeated use over time or a flare up, he provided an opinion based on the Veteran's statements describing functional loss: the examiner opined that pain and swelling caused functional loss. The examiner described the functional loss in terms of range of motion limitations for flexion at 0 to 120 degrees; for extension, 120 to 0 degrees. Id. at 9, 11. The examiner did not find additional conditions, complications, or symptoms, due to the Veteran's right knee disability, to include ankylosis. Id. at 13, 17. A. Entitlement to service connection for psoriasis on a direct basis. Turning to the Veteran's claim for disability compensation, the first question is whether she has established entitlement to service connection under 38 C.F.R. § 3.303. That is, on a direct basis. To answer that question, the first issue is whether the Veteran has a current disability. The Veteran has been diagnosed with psoriasis, most recently during the July 2021 VA examination. See VA DBQ at 2. So, the record reflects a diagnosed skin disorder. The next issue is whether the Veteran's skin disorder began in or was incurred during service. The Veteran's STRs weigh strongly against finding psoriasis was incurred during service. Given that the Veteran had visited sick-call with complaints of hives, it is apparent to the Board she was alert to observable changes on her body. See April 15, 2005, STR by C.G., MD. Because she also sought medical attention for observations of hives, the Board finds it is likely she would have reported symptoms of psoriasis, like itchy, scaling skin, if observed. So, the Board finds the STRs credible. Because the STRs do not reference medical complaints or diagnoses of a skin disorder, they were assigned significant weight against finding her skin disorder existed during service. Any contention that the Veteran may have observed signs of a skin disorder but was not severe enough to seek medical attention would be without merit. The Veteran has consistently maintained psoriasis was first observed long after service, around 2015. See April 2017 VA DBQ at 2 (Reporting psoriasis began around 2015); Transcript dated November 2020 at 19 (Reporting she observed signs of psoriasis after service); June 2021 VA DBQ at 2 (Reporting psoriasis began a few years before the examination). The Veteran has personal knowledge of changes observed on her body, like hives, itchy, scaly patches. So, she is competent to report it. Layno v. Brown, 6 Vet. App. 465, 469 (1994).Given the consistency of her reports to the VA and medical providers, the Board finds her reports during treatment credible. Combined with the general reliability afforded to reports to medical providers, her lay statements and observation were assigned great weight against finding an in-service incurrence. Although Dr. M.V. provided a favorable opinion relating the Veteran's skin disorder to her service-connected acquired psychiatric disorders, his opinion does not suggest psoriasis manifested during service. Dr. M.V. did not discuss when the disorder may have initially manifested. Without any indication when Dr. M.V. believed the Veteran's psoriasis began, it does not help the Board evaluate the issue of an in-service incurrence; therefore, it was not probative towards evaluating an in-service incurrence. See June 2018 Record by M.V., MD. In this case, the evidence weighs against finding the Veteran's skin disorder was incurred in or began during service. She has consistently maintained the disorder began several years after service. Her STRs support her assertions as they do not reference medical complaints of symptoms used to describe her psoriasis. So, there is no doubt on the issue to be resolved in her favor. Gilbert, 1 Vet. App. at 54. The next issue is whether there is a nexus between the Veteran's skin disorder and service. The Veteran's STRs weigh against finding a nexus, she did not report observing signs of her skin disorder during service. Given that multiple medical professionals evaluated her through service and no reference to skin disorders is found in her recordsthe Board assigned her STRs significant weight against a nexus. See November 1, 2005, Report of Medical Examination (Clinical examination of skin was normal); December 15, 2008, Report of Medical Examination January 27, 2009 (Clinical examination of skin was normal); Report of Medical History at 1 (Clinical examination of skin was normal). Although the Veteran has not expressed a belief her disorder is due to service, she has asserted she conducted her own research to determine what may have caused her disorder; so, it is important to point out any lay diagnosis would not have been probative towards deciding a nexus. See Transcript dated November 2020 at 21. She is competent to report observable symptoms, like itchy skin, but she has not demonstrated she has the medical knowledge, training, or experience to opine on the cause of her skin disorder. Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (Fed. Cir. 2007). Diagnosing psoriasis is medically complex, requiring the ability to distinguish it from other skin disorders. So, any conclusion she reached based on her investigation is not probative towards deciding a nexus. Even though the Veteran is not competent to render an opinion on an etiological link between psoriasis and service, her lay statements provide sufficient evidence for the Board to decide there was no need to obtain one. Jandreau, 492 F.3d at 1377. An examination is warranted 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 or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Considering the record reflects medical evidence showing the Veteran did not have psoriasis during service and she has not asserted it is due to service, the Board finds obtaining a medical opinion on that matter is not warranted. As noted above, the Veteran has not alleged she observed symptoms during service nor is there evidence suggestive of an in-service incurrence. Also, a search of her records did not raise the inference her diagnosed skin disorder is associated with her service in the Navy medical corps or any other event during service. In this case, the evidence is not evenly balanced on the issue of a nexus. The Veteran has not expressed a belief her psoriasis is due to her service; instead, she has consistently maintained it is secondary to a service-connected disorder. So, even though her STRs are the only items of medical evidence, they are sufficient to decide the matter of a nexus. Given that they weigh against finding a nexus, doubt is not resolved in the Veteran's favor. Gilbert, 1 Vet. App. at 54. So, the Board finds there is no nexus between the Veteran's sleep disorder and any period of active service. Although the record reflects the Veteran has been diagnosed with a current disability, the evidence does not support finding it began during service. Nor does the evidence support finding a nexus. Accordingly, she has not established entitlement to service connection on a direct basis. 38 C.F.R. § 3.303. B. Entitlement to service connection on a secondary basis. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.310(a) or (b). That is, on a secondary basis. To answer that question, the first issue is whether the Veteran has a service-connected disability. The record reflects multiple service-connected disabilities, to include chronic allergic rhinitis, hallux valgus (bunions) on both feet, right knee DJD, bilateral lower extremity radiculopathy, as well as major depressive disorder and obsessive compulsive disorder (acquired psychiatric disorder). Although the records show she has many service-connected disabilities, she has not indicated psoriasis is secondary to any of them except her acquired psychiatric disorders. The Board notes a search of the record did not raise the inference of a claim for service connection under 38 C.F.R. § 3.310 based on any other service-connected disability. The next issue is whether the Veteran's skin disorder was proximately caused by her service-connected acquired psychiatric disorders. Although the Veteran expressed she conducted her own online research on a connection between psoriasis and psychiatric disorders, she did not provide enough detail on the medical information she relied on that helps the Board find causation. First, she is not qualified to opine on a causal link between psoriasis and psychiatric disorders. Jandreau, 492 F. 3d at 1376. So, her expressed belief without any reference to the data she relied on is of no probative value when evaluating the issue. Second, because the data she relied on was not made available for the Board to consider on its own meritsher general reference to web-based evidence is of no probative value towards finding causation. The Board recognizes the Veteran's belief is, in part, based on what Dr. M.V. may have told her. The Veteran is competent to report that a medical professional told her there is a connection between psoriasis, stress, and mental health disorders. Layno, 6 Vet. App. at 469. Given that Dr. M.V.'s notes were found in the record, his opinion was evaluated on its own merits and found to be of little probative value. See January 12, 2018, VAMC Record. Dr. M.V.'s medical opinion was general and not sufficiently tailored to the particulars of the Veteran's claim. Dr. M.V.'s opinion was written in a way that suggests multiple skin disorders are related to different types of psychiatric disorders. Without more, the Board cannot evaluate how his medical knowledge was applied to the specifics of the Veteran's claim. Nievez-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2006). So, the probative value of the opinion was diminished. Because the opinion broadly linked many skin and psychiatric disorders, it did not provide much information that was helpful to the Board when evaluating the issue. So, it was assigned little probative weight towards finding causation. In contrast, the examiner who prepared the June 2021 VA Medical Opinion discussed the specific disorders at issue when concluding there is no causal link between them. See Medical Opinion at 4-5. The examiner based his opinion on the record, personal examination, and observations of the Veteran. So, the Board finds the examiner was informed of the relevant details of the Veteran's past medical history when rendering his opinion. Nievez-Rodriguez, 22 Vet. App. at 301. When the examiner's opinion is read as whole, it is apparent to the Board he did not find a medical basis to conclude the Veteran's acquired psychiatric disorders caused psoriasis. The examiner relied on studies that evaluated other studies when coming to his conclusion, which indicates he considered a large body of medical data on the matter when reaching his conclusion. Given that the examiner is qualified to interpret that data and apply it to the Veteran's claim, the Board finds the evidence he relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. As to the issue of causation, the Board finds the evidence is not approximately balanced. Although the Veteran believes there is a link between psoriasis and MDD or OCD, the Board finds the opinions by Dr. M.V. and the examiner who prepared the June 2021 VA Medical Opinion more probative on the issue of causation. Because Dr. M.V.'s favorable opinion was too general to help decide the claim, its probative value was outweighed by the June 2021 VA Medical Opinion. Given that the VA Medical Opinion concluded the Veteran's psoriasis is not due to her psychiatric disorders, doubt is not resolved in her favor. Gilbert, 1 Vet. App. at 54. Accordingly, she is not entitled to service connection under 38 C.F.R. § 3.310(a). The next issue is whether the Veteran's psoriasis was aggravated by her service-connected psychiatric disorder. The examiner who prepared the June 2021 Medical Opinion concluded the Veteran's psoriasis was not aggravated by her acquired psychiatric disorder. See VA Medical Opinion at 3, 4-5. Based on a reading of the examination as a whole, the examiner concluded there is not enough medical data on the subject to conclude stress aggravates psoriasis. Although the examiner emphasized the symptom of psychological stress, it is apparent to the Board he did not find any other symptoms of her psychiatric disorder aggravated psoriasis. The examiner indicated that, based on his knowledge and medical understanding, the Veteran's particular psychiatric disorders (MDD and OCD) do not impact psoriasis. Id. at 4. Given that the examiner is qualified to opine on the likelihood that her psychiatric disorder aggravates psoriasis, the Board is able to evaluate whether the data he relied on connects to his conclusion. Nievez-Rodriguez, 22 Vet. App. at 301. So, the Board assigned it significant weight against finding aggravation. As to the issue of aggravation, the Board finds the evidence is not approximately balanced. The June 2021 medical opinion is the only medical evidence of record that addressed whether the Veteran's psoriasis was aggravated by her service-connected psychiatric disorders. The examiner who prepared the opinion concluded there has been no aggravation. As a result, the competent evidence on this issue weighed against the Veteran's claim. So, doubt is not resolved in her favor. Gilbert, 1 Vet. App. at 54. Accordingly, she is not entitled to service connection under 38 C.F.R. § 3.310(b). In sum, the Veteran has not established entitlement to service-connection on a direct or secondary basis. Also, consideration of entitlement to service connection based on chronicity or continuity of symptomatology is not warranted. This is because her diagnosed psoriasis is not a chronic disability listed under the relevant VA regulation. 38 C.F.R. §§ 3.303(b); 3.309(a), 3.310. 2. Entitlement to an increased disability rating greater than 10 percent for right knee DJD. The Veteran contends that the current severity of her right knee DJD(right knee disability) warrants a greater than 10 percent rating. See June 2017 Notice of Disagreement(NOD). The question for the Board is whether the Veteran has established entitlement to a greater than 10 percent disability rating for service-connected right knee disability at any time during the appeal period. For the reasons discussed below, the Board concludes a higher disability rating is not warranted. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 U.S.C. § 1155; 38 C.F.R., Part 4. If there is a question as to which evaluation to apply to the Veteran's disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). If later evidence indicates that the degree of disability increased or decreased following the assignment of the initial rating, "staged" ratings may be assigned for separate periods of time. Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007). When assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must, in addition to applying scheduler criteria, also consider evidence of pain, weakened movement, excess fatigability, or incoordination. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 204-207 (1995).Given the nature of the present claim for a higher initial evaluation, the Board has considered all evidence of severity since the effective date for the award of service connection in September 2011.Fenderson v. West, 12 Vet. App. 119 (1999). Although pain may cause functional loss, pain itself does not constitute functional loss. 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, 36- 39 (2011). The Veteran's service-connected right knee disability is rated under DC 5003-5260. Hyphenated diagnostic codes are used when a rating under one DC (5003) requires the use of an additional DC to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. The hyphenated codes for the Veteran's right knee disability reflect that limited flexion (bending) of the knee is the basis for the rating assigned under DC 5260. Under that code, when flexion is limited to 60 degrees, a noncompensable (0 percent) disability rating is warranted. When it is limited to 45 degrees, a 10 percent disability rating is warranted. When limitation of flexion is at 30 degrees, a 20 percent disability rating is warranted. When it is limited to 15 degrees, a 30 percent disability rating is warranted. A 30 percent rating is the maximum schedular rating under 5260. 38 C.F.R. § 4.71a. Any reasonable doubt regarding a degree of disability is resolved in favor of the Veteran. 38 C.F.R. § 4.3. Reasonable doubt exists when there is an approximate balance of positive and negative evidence for and against the claim. 38 C.F.R.§ 3.102. A. Entitlement to a greater than 10 percent rating under DC 5260. After reviewing the record, the Board concludes the evidence does not support finding the Veteran's right knee disability more nearly approximates the criteria DC 5260 requires for a greater than 10 percent disability rating at this time. The Board recognizes the Veteran's lay statements describing pain and functional loss. She has personal knowledge of symptoms like pain and stiffness. Also, functional loss caused by her symptoms, like difficulties walking up stairs. So, she is competent to report it. Layno, 6 Vet. App. at 469. The record shows she consistently reported to VA and medical providers that her right knee pain reached a level of severity that she had difficulty performing a variety of activities, like squat, walk upstairs, and bend over. Given the consistency of her reports and the added reliability of statements to medical providers, the Board finds her lay statements and observations credible. Although the Board finds the Veteran's observations of pain and functional loss crediblethey are not sufficient to assign an increased disability rating under DC 5260. Under 5260, disability ratings are based on evidence of functional limitation; specifically, limitation of flexion. Mitchell, 25 Vet. App. at 36-39. Also, the extent of functional limitations is measured in terms of degrees of limited movement. 38 C.F.R. § 4.71a. A Veteran's descriptions of symptoms may be helpful in making that determination, but the statements of record here do not provide enough information to help the Board translate her knee problems into degrees of limited flexion. For example, her reports of difficulties walking up and down stairs are too general to translate into degrees of limited flexion. Thus, her statements were assigned some, but not significant, probative weight in favor of a greater than 10 percent rating. The examiner who prepared the June 2021 VA disability examination provided range of motion estimates based on the Veteran's lay observations; however, the range of motion estimates do not support the assignment of a greater than 10 percent rating. Given that the examiner based his opinion on the Veteran's lay statements and record, the Board finds he was informed of the relevant details of the Veteran's past medical history. Nievez-Rodriguez, 22 Vet. App. at 301. Because the examiner also considered functional loss due to pain on flare-ups and quantified those effects in terms of range of motion limitationsthe Board finds the June 2021 VA DBQ provides a clear picture of the extent to which pain is disabling. Sharp, 29 Vet. App. at 34-35; Mitchell, 25 Vet. App. at 37-38, 44. Based on the examiner's description of range of motion limitations due to pain, the Veteran is entitled to the 10 percent disability rating she is currently assigned. The examiner opined the Veteran's right knee disability on flare-ups manifested in flexion no less than 120 degrees. See June 2021 VA DBQ at 9, 11. Because the next higher rating (20 percent) under DC 5260 requires limited flexion at 45 degrees or less, the VA DBQ weighs strongly against finding the assignment of a greater than 10 percent rating is warranted. The Board notes that a search of the record did not show evidence that supports finding a greater than 10 percent rating was warranted at any time during the appeal period before the June 2021 VA DBQ was conducted. So, the Board finds the June 2021 VA DBQ captures the severity of her right knee disability throughout the entire appeal period. Hart, 21 Vet. App. at 509-10. In this case, the evidence is not approximately balanced in favor of finding a greater than 10 percent disability rating for her service-connected right knee disability is warranted at any time across the appeal period. Although the Veteran believes the limited motion she observed during the relevant period warrants a higher rating, the more probative June 2021 VA DBQ provides range of motion findings that do not meet the criteria DC 5260 requires for the assigment of a 20 percent disability rating. So, doubt is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds that a disability rating greater than 10 percent for right knee DJD is not warranted at this time. DC 4.71a. B. Entitlement to a greater than 10 percent disability rating under other applicable diagnostic codes. Because the Board must consider all other potentially applicable DCs, the next question is whether a higher rating under other applicable DCs is available. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). The Board finds that, based on the Veteran's disability picture, the applicable DCs do not provide for a greater than 10 percent disability rating. The applicable DCs are 5003 (degenerative arthritis) and 5257 (instability). Given that the June 2021 VA DBQ shows normal extension, a rating for right knee extension under 5261, is not warranted. Given that the Veteran has been diagnosed with degenerative arthritis of the right knee, DC 5003 (degenerative arthritis) applies to this claim. Under DC 5003 (pre- and post-February 7, 2021), a rating of 20 percent requires evidence of occasional incapacitating exacerbations. Although 5003 does not define "incapacitating exacerbation," the Board likens it to an "incapacitating episode," which is defined as a period of acute signs and symptoms that require bed rest prescribed by a physician. 38 C.F.R. § 4.71a, DC 5243, Note 1. Here, the Board recognizes the Veteran has described occasions during flare-ups when she has to refrain from some activities, but has not indicated she has been prescribed bed rest by a physician. See Transcript dated November 2020 at 13. So, the assignment of a greater than 10 percent disability rating under that code is not warranted. The Board recognizes the Veteran has described right knee instability, to include an occasion her knee gave out; however, she has already been assigned a separate rating for right knee instability under DC 5257 (10 percent from April 2010). Also, the Veteran has not appealed the disability rating assigned. So, the issues of a greater than 10 percent rating for instability of each knee are not on appeal before the Board. In any event, the June 2021 VA DBQ did not provide findings that indicate a greater than 10 percent rating is warranted at this time. See VA DBQ at 1, 4, 13. In sum, the available evidence does not show that the severity of the Veteran's service-connected right knee disability rated under DC 5003-5260 warrants a greater than 10 percent rating at any time across the appeal period. Hart, 21 Vet. App. at 505. Nor under any other applicable code. 38 C.F.R. § 4.7. 3. Entitlement to a greater than 10 percent disability rating for lumbar spine anterolisthesis with DDD. The Veteran contends that the current severity of her lumbar spine anterolisthesis with DDD (back disability) warrants a greater than 10 percent rating. See June 2017 NOD. The question for the Board is whether the Veteran has established entitlement to a greater than 10 percent disability rating for her back disability at any time during the appeal period. For the reasons discussed below, the Board concludes a higher disability rating is not warranted. The Veteran's service connected back disability is rated as 10 percent disabling under DC 5242. Under that code, rates are based on limitation of flexion. That code provides that a 20 percent disability rating is warranted when forward flexion of the thoracolumbar spine is greater than 30 degrees but less than 60 degrees, or the combined range of motion of the thoracolumbar spine is less than 120 degrees. The next higher rating, a 40 percent rating, is warranted when there is forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." DORLAND'S ILLUSTRATED MEDICAL DICTIONARY (DORLANDS) 92 (33rd ed. 2020). A 50 percent disability evaluation is warranted when there is evidence of unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent disability rating is warranted when there is evidence of unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. A. Entitlement to a greater than 10 percent rating under DC 5242. After reviewing the record, the Board concludes the evidence does not support finding the Veteran's back disability more nearly approximates the criteria DC 5242 requires for a greater than 10 percent disability rating at this time. The Board recognizes the Veteran's lay statements describing pain and functional loss. She has personal knowledge of symptoms like pain and stiffness. Also, functional loss, like difficulty bending over to get dishes out of the dishwasher. So, she is competent to report it. Layno, 6 Vet. App. at 469. Throughout the appeal period she has consistently reported to the VA and medical providers she observes pain, difficulties standing, walking, and bending over. Given the consistency of her reports and the added reliability of statements to medical providers, the Board finds her lay statements and observations credible. Although the Board finds the Veteran observations of pain and functional loss crediblethey are not sufficient to assign an increased disability rating under DC 5242. Under 5242, disability ratings are assigned based on evidence of functional limitations; specifically, limited bending, rotating, and moving side to side. Mitchell, 25 Vet. App. at 36-39. Also, the functional limitations are measured in terms of degrees of limited movement. 38 C.F.R. § 4.71a. Here, the Veteran's described symptoms do not provide enough information to help the Board translate her observations of pain and functional loss, like difficulties bending, into degrees of limited flexion and rotation. For example, the Veteran's report of problems bending over to get dishes out of the dishwasher does not provide data that can be translated into degrees of limited forward flexion. See Transcript date November 2020 at 4. Similarly, her reports of difficulties making sharp turns do not provide enough detail for the Board to approximate the degree of limited rotation. Id. at 5. Thus, her statements were assigned some, but not significant, probative weight in favor of assigning a greater than 10 percent rating. The examiner who prepared the June 2021 VA disability examination provided range of motion estimates that included consideration of the Veteran's lay observations; however, the estimates do not meet the criteria DC 5242 requires for a greater than 10 percent rating. Given that the examiner reviewed the file and the Veteran's statements, the Board finds he was informed of the relevant details of the Veteran's past medical history. Nievez-Rodriguez, 22 Vet. App. at 301. Because the examiner also considered functional loss due to pain on flare-ups and quantified those effects in terms of range of motion limitationsthe Board finds the June 2021 VA DBQ provides a clear picture of the extent to which pain is disabling. Sharp, 29 Vet. App. at 34-35; Mitchell, 25 Vet. App. at 37-38, 44. Based on the examiner's description of range of motion limitations due to pain, the Veteran is entitled to the 10 percent rating she is currently assigned. The examiner opined the Veteran's back disability on flare-ups manifested in flexion no less than 70 degrees. See June 2021 VA DBQ at 7, 8. Given that the next higher rating (20 percent) under DC 5242 requires forward flexion of the spine to be between 30 degrees and 60 degrees, the VA DBQ weighs strongly against finding the assignment of a greater than 10 percent rating is warranted. Also, because the combined range of motion for the thoracolumbar spine was not less than 170 degrees, consideration of a higher rating based on the combined range of motion measurements is not warranted. A 20 percent disability rating under DC 5242 is warranted when the combined range of motion of the thoracolumbar spine is less than 120 degrees. 38 C.F.R. § 4.71a. Given that disability ratings greater than 20 percent require greater loss of motion, consideration of higher than 20 percent ratings are not warranted. The Board recognizes the Veteran has reported her back disability had worsened during the appeal period; however, the June 2021 VA DBQ postdates those reports. So, the Board finds the VA DBQ captures the current severity of her back disability. Given that it shows pain and limited movement do not result in functional loss that warrants a greater that 10 percent rating, consideration of staged ratings is not warranted. Hart, 21 Vet. App. at 509-10. In this case, the evidence is not approximately balanced in favor of finding a greater than 10 percent disability rating for her service-connected back disability is warranted at any time across the appeal period. Although the Veteran believes the limited motion she observed during the relevant period warrants a higher rating, the more probative June 2021 VA DBQ shows range of motion findings that do not meet the criteria DC 5242 requires for the assigment of a 20 percent or greater disability rating. So, doubt is not resolved in the Veteran's favor. 38 C.F.R. § 4.3. Accordingly, the Board finds that a disability rating greater than 10 percent is not warranted at this time. 38 C.F.R. § 4.71a. B. Entitlement to a greater than 10 percent disability rating under other applicable diagnostic codes. The Board finds that, based on the Veteran's disability picture during the appeal period, the applicable DCs do not provide for a greater than 10 percent disability rating. The applicable codes are DCs 5003 (degenerative arthritis) and 8521 (paralysis of peroneal nerve). She has not been diagnosed with IVDS nor has her back been found to be ankylosed. See April 2017 and June 2021 VA DBQs at 9, 12. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." DORLAND'S at 92. So, consideration of ratings under the applicable codes for those conditions is not warranted. 38 C.F.R. § 4.7. Under DC 5003 (pre- and post-February 7, 2021), a rating of 20 percent requires evidence of occasional incapacitating exacerbations. Here, the Board recognizes the Veteran has described pain and difficulties bending over, but she has not asserted she has been prescribed bed rest by a physician. See Transcript dated November 2020 at 3-6. So, a greater than 10 percent disability rating under that code is not warranted. The Board recognizes the Veteran has described signs of radiculopathy, to include tingling and numbness running down her legs; however, she has already been assigned a separate rating for bilateral lower extremity radiculopathy under DC 8521 (10 percent from April 2010). She has not appealed the disability ratings assigned. So, the issues of increased ratings above 10 percent for radiculopathy are not on appeal before the Board. In any event, the June 2021 VA DBQ did not provide findings that indicate a greater than 10 percent rating is warranted. See VA DBQ at 11.The Board recognizes the examiner did not find radiculopathy at all; however, the April 2017 VA DBQ noted radiculopathy and found it was mild. See VA DBQ at 9. In sum, the evidence of record does not show the current severity of the Veteran's service-connected back disability rated under DC 5242 warrants a rating greater than 10 percent rating at any time across the appeal period. Hart, 21 Vet. App. at 505. Nor under any other applicable code. 38 C.F.R. § 4.7. The Board notes that this case does not raise a claim for a Total Disability Rating Based Upon Individual Unemployability (TDIU). Although the record shows the Veteran has claimed her right knee and back disabilities have interfered with her ability to work, the record also shows she is currently employed. See February 28, 2020 VAMC record by K.J. (Noting the Veteran is working in an administrative vocation). Thus, there is no indication she is unable to secure or follow a substantially gainful occupation as a result of a service-connected disability. 38 C.F.R. § 4.16(a); Rice v. Shinseki, 22 Vet. App. 447, 454 (2009). The Board regrets a more favorable decision could not be reached in the Veteran's case. DAVID L. WIGHT Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dean, Michael S. 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.