Citation Nr: 21071743 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 13-34 977 DATE: December 1, 2021 ORDER New and material evidence has been received and the claim for service connection for dizziness has been reopened, and to this extent, the appeal is granted. New and material evidence has been received and the claim for service connection for a right foot disability has been reopened, and to this extent, the appeal is granted. Entitlement to a rating greater than 10 percent for left knee patellofemoral syndrome is denied. From July 9, 2020 to June 2, 2021, entitlement to continuation of the 10 percent rating for right knee residuals of patellofemoral syndrome, limitation of flexion, is warranted and to this extent, the appeal is granted Prior to June 3, 2021, entitlement to a rating greater than 10 percent for right knee residuals of patellofemoral syndrome, limitation of flexion, is denied. Entitlement to an effective date of January 26, 2016 for a separate 20 percent rating for right knee degenerative arthritis, meniscal tear, is granted. Entitlement to a total rating from June 3, 2021 for right knee total arthroplasty for the one year period (provided under the rating criteria in effect prior to February 7, 2021) is granted. Entitlement to a compensable rating for service-connected hypertension is denied. REMANDED Entitlement to service connection for dizziness, to include as secondary to service-connected tinnitus and hypertension, is remanded. Whether new and material evidence has been submitted to reopen the claim for service connection for headaches is remanded. Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for chest pain other than costochondritis, to include as secondary to service-connected hypertension, is remanded. Entitlement to a rating greater than 10 percent for residuals of right elbow fracture with retained hardware is remanded. Entitlement to a compensable rating for limitation of extension of the right elbow is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. FINDINGS OF FACT 1. In a June 2011 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for dizziness; the Veteran did not appeal the decision and new and material evidence was not received within the one-year appeal period. 2. In a March 2005 rating decision, the VA RO denied service connection for a right foot disability; the Veteran did not appeal the decision and new and material evidence was not received within the one-year appeal period. 3. Evidence associated with the record since the June 2011 and March 2005 decisions relates to unestablished facts and raises a reasonable possibility of substantiating the claims of entitlement to service connection for dizziness and a right foot disability. 4. The Veteran's left knee flexion has not been limited to 30 degrees or less, even with consideration of functional impairment due to pain after repetitive use and flare-ups. 5. Prior to June 3, 2021, the Veteran's right knee disability manifested as painful limitation of flexion; however, at no time prior to June 3, 2021 was his right knee flexion limited to 30 degrees or less, even with consideration of functional impairment due to factors such as pain and flare-ups. 6. From January 26, 2016 to June 2, 2021, the Veteran's right knee disability manifested as a torn meniscus with frequent episodes of "locking," pain, and effusion into the joint. 7. The Veteran's claim for an increased rating for his right knee disability was pending prior to the February 7, 2021 revision of the rating criteria; the rating criteria in effect prior to February 7, 2021 for total knee replacement are more favorable and provide for a 100 percent rating for one year following the Veteran's surgery on June 3, 2021. 8. During the appeal period, the Veteran's diastolic pressure was not predominantly 100 or more; his systolic pressure was not predominantly 160 or more; and his diastolic pressure was not and has not historically been predominantly 100 or more and require continuous medication for control. CONCLUSIONS OF LAW 1. The criteria for reopening the previously denied claim for service connection for dizziness have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 2. The criteria for reopening the previously denied claim for service connection for a right foot disability have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156(a). 3. The criteria for a rating in excess of 10 percent for left knee patellofemoral syndrome have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 4. For the entire period prior to June 3, 2021, the criteria for a 10 percent rating, but not higher, for right knee limitation of flexion were met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5260. 5. From January 26, 2016 to June 2, 2021, the criteria for a separate 20 percent rating for right knee meniscal tear have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5258. 6. The criteria for a 100 percent rating from June 3, 2021 for one year following the right knee total replacement are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5055 (2020). 7. The criteria for a compensable rating for service-connected hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.7, 4.21, 4.31, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from October 1984 to October 2004 and from June 2008 to June 2009. These matters come before the Board of Veterans' Appeals (Board) on appeal from a February 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held in September 2017 before the undersigned Veterans Law Judge. A transcript of the hearing testimony is in the claims file. In January 2018, the Board remanded these matters for additional development, which has been substantially completed. See Stegall v. West, 11 Vet. App. 268, 271 (1998). New and Material Evidence If a claim of entitlement to service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision-makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The credibility of the evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The threshold for reopening is low. Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). 1. New and material evidence has been received and the claim for service connection for dizziness has been reopened; to this extent the appeal is granted. The RO denied the Veteran's claim of service connection for dizziness in a June 2011 rating decision, finding that the Veteran had not presented evidence of a disability that was related to service. The Veteran was provided notice of this decision and his appellate rights, but he did not appeal the decision or submit new and material evidence within one year of the decision. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2010). The evidence received since the June 2011 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156. For example, in March 2015, the Veteran testified before the Decision Review Officer (DRO) that his first episode of dizziness manifested in conjunction with an episode of his service-connected tinnitus. This new evidence addresses the reason for the previous denial; that is, evidence of a current disability that is related to service or a service-connected disability. The credibility of this evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened and will be considered on the merits. 2. New and material evidence has been received and the claim for service connection for a right foot disability has been reopened, and to this extent, the appeal is granted. The RO denied the Veteran's claim of service connection for a right foot disability in a March 2005 rating decision, finding that while the Veteran had chronic foot pain in service, to include pes planus that was severe and symptomatic at separation from service, the evidence did not show a current disability during the pendency of the claim. The Veteran was provided notice of this decision and his appellate rights but did not appeal the decision or submit new and material evidence within one year of the decision. Therefore, the decision is final. See 38 C.F.R. §§ 3.156, 20.302, 20.1103 (2004). The evidence received since the March 2005 rating decision includes evidence that is both new and material to the claim. See 38 C.F.R. § 3.156. For example, an October 2013 VA examination report addressing the foot shows plantar fasciitis and right foot pain. This new evidence addresses the reason for the previous denial; that is, evidence of a current disability, and raises a reasonable possibility of substantiating the claim. The credibility of this evidence is presumed for purposes of reopening the claim. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). Accordingly, the claim is reopened and will be considered on the merits. Increased Rating Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155; 38 C.F.R. Part IV. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. Pertinent regulations do not require that all cases show all findings specified by the Rating Schedule, but that findings sufficiently characteristic to identify the disease and the resulting disability and above all, coordination of rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21. Therefore, the Board has considered the potential application of various other provisions of the regulations governing VA benefits, whether or not they were raised by the Veteran, as well as the entire history of the veteran's disability in reaching its decision. Schafrath v. Derwinski, 1 Vet. App. 589, 595 (1991). When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the U.S. Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. In deciding this appeal, the Board has considered whether separate ratings for different periods of time, based on the facts found, are warranted, a practice of assigning ratings referred to as "staging the ratings." See Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2008). 3. Entitlement to a rating greater than 10 percent for left knee patellofemoral syndrome is denied. The Veteran seeks a rating greater than 10 percent for his left knee patellofemoral syndrome, which has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5014, for osteomalacia rated as limitation of flexion of the knee. Diagnostic Code 5014 provides that osteomalacia shall be rated on limitation of motion of the affected parts as degenerative arthritis, which is evaluated under Diagnostic Code 5003. Under Diagnostic Code 5003, degenerative arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. 38 C.F.R. § 4.71a. When limitation of motion due to arthritis is noncompensable under the appropriate diagnostic code, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion, to be combined, not added under Diagnostic Code 5003. In the absence of limitation of motion, Diagnostic Code 5003 provides for a 10 percent rating with X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups. A 20 percent rating under Diagnostic Code 5003 requires involvement of two or more major joints or two or more minor joint groups with occasional incapacitating exacerbations. Normal range of knee motion is 140 degrees of flexion and zero degrees of extension. 38 C.F.R. § 4.71, Plate II. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. VA amended some of the rating criteria for disabilities of the knee and leg; however, Diagnostic Code 5260 was unchanged. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The evidence includes the October 2011 VA examination report, which shows the Veteran reported having flare-ups of the knees. On examination, left knee flexion measured 90 degrees and extension measured 0 degrees. There was no objective evidence of pain. Repetitive use testing was not completed due to the Veteran's back pain; however, the examiner indicated that pain and swelling would contribute to functional impairment after repetitive use. The examiner did not estimate range of motion (ROM) after repetitive use or during flare-ups. The Veteran had another examination in December 2016. The Veteran reported pain and that he used a knee brace during daytime activities. He denied having flare-ups and indicated that he did not have functional loss or impairment after repeated use over time. ROM testing showed flexion to 110 degrees and extension to 0 degrees. No additional loss of motion was observed after repetitive use testing. Pain was not observed on examination. No other symptoms were observed. During his September 2017 hearing before the Board, the Veteran testified that he had sharp knee pain and that the pain had worsened since the December 2016 VA examination. He had to stop working as a bus driver due to his knees. The Veteran had another examination of the left knee in July 2020. He described having more pain and difficulty walking over the last 18 months. He reported having pain on movement, difficulty moving, and swelling. The Veteran said his flare-ups occurred daily, were moderate in severity, and lasted 1 to 2 hours. He stated that at times, pain was sharp and prevented him from walking. He could not run or take long walks. ROM testing showed the left knee flexion was to 85 degrees and flexion was to 0 degrees. Decreased ROM caused difficulty walking. The examiner observed pain on flexion and extension, and stated that it caused functional loss. The examiner rated the pain as moderate. The Veteran was not able to perform repetitive use testing due to his fear of pain. The examiner estimated that after repetitive use over time and during flare-ups, the Veteran's flexion would be limited to 65 degrees due to pain. The examiner noted the Veteran's occupation as a bus driver and that the left knee disability affected his ability to walk. VA and private treatment records do not show ROM findings indicating that the Veteran's left knee flexion was limited to 30 degrees or less, even with consideration of functional impairment due to pain. Based on the evidence, the Board finds that the preponderance of the evidence is against a rating in excess of 10 percent for the left knee disability. The Board acknowledges the Veteran's lay reports of symptoms and that there was functional loss due to pain, pain during flare-ups, and pain during repetitive use over time. However, even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements that his pain affected his ability to walk distances and drive a bus, his symptoms would not result in limitation of motion more nearly approximating flexion limited to 30 degrees. The Board reviewed all VA and private treatment records, to include VA examinations. At its worst, the left knee flexion was limited to 65 degrees during flare-ups or after prolonged use, which is motion far greater than the limitation to 30 degrees required for a 20 percent rating. The Board has also considered the other Diagnostic Codes pertaining to the knee and leg. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). However, in this case, the Veteran's left knee extension has not been limited and he has not had other left knee symptoms warranting consideration of other diagnostic codes. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for the left knee disability. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. The appeal is denied. 4. Entitlement to a 10 percent rating prior to June 3, 2021 for right knee residuals of patellofemoral syndrome, limitation of flexion, is granted. 5. Entitlement to a 20 percent rating from January 26, 2016 for right knee degenerative arthritis, meniscal tear is granted. The Veteran seeks an increased rating for his right knee disability. During the pendency of the claim, the RO has rated the right knee disability under several diagnostic codes. Prior to July 9, 2020, the Veteran had a 10 percent rating under 38 C.F.R. § 4.71a, Diagnostic Code 5260-5014 for residuals of right patellofemoral syndrome, rated as limitation of flexion. From July 9, 2020 to June 2, 2021, the Veteran's right knee disability was rated 20 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5003-5258, for degenerative arthritis rated as dislocated semilunar cartilage. On June 3, 2021, the Veteran had a total knee replacement and since this date, his right knee has been rated under 38 C.F.R. § 4.71a, Diagnostic Code 5055, knee replacement. Significantly, VA revised the rating criteria for the knees, effective February 7, 2021. With regard to the ratings concerning the knee, the revisions revised 38 C.F.R. § 4.71a, Diagnostic Codes 5055, 5257, and 5262. Diagnostic Codes 5258, 5260, and 5261 did not change. The amended criteria, if favorable to the Veteran's claim, can only be applied for the period from the effective date of the regulatory change; however, the old regulations will be considered for the periods both before and after the change was made. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Diagnostic Codes 5260-5014 and 5003 are addressed above. Under Diagnostic Code 5258, a 20 percent rating is warranted for dislocation of semilunar cartilage with frequent episodes of "locking, pain", and effusion into the joint. 38 C.F.R. § 4.71a, Diagnostic Code 5258. No higher ratings are provided for this diagnostic code. Under Diagnostic Code 5260, a noncompensable rating is warranted for flexion limited to 60 degrees. A 10 percent rating is warranted for flexion limited to 45 degrees. A 20 percent rating is warranted for flexion limited to 30 degrees. A 30 percent rating is warranted for flexion limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. The Board acknowledges that the RO changed the diagnostic code for the Veteran's right knee disability on July 9, 2020 from 38 C.F.R. § 4.71a, Diagnostic Code 5260-5014, for residuals of right patellofemoral syndrome, rated as limitation of flexion, to 38 C.F.R. § 4.71a, Diagnostic Code 5003-5258, for degenerative arthritis rated as dislocated semilunar cartilage. However, as discussed below, the Board finds that the Veteran is entitled to the 10 percent rating for limitation of flexion as well as a separate rating for the meniscal tear. The evidence includes the October 2011 VA examination report, which shows the Veteran reported having flare-ups of the knees. On examination, right knee flexion measured 90 degrees and extension measured 0 degrees, with pain at 0 degrees. Repetitive use testing was not completed due to the Veteran's back pain however, the examiner indicated that pain and swelling would contribute to functional impairment after repetitive use. The examiner did not provide estimates of ROM after repetitive use or during flare-ups. VA treatment records include a January 26, 2016 MRI report, which shows a tear of the posterior horn of the medial meniscus and mild degenerative joint disease. Also noted was small joint effusion in the knee with fluid at the prepatellar bursa. The Veteran had physical therapy in 2016. A March 2016 therapy note shows his right knee flexion was 90 degrees with full extension, with guarding. An April 2016 physical therapy note shows the Veteran's right knee flexion was to 100 degrees with full extension. During the December 2016 VA examination, the Veteran reported ongoing pain. He used a knee brace for support during daytime activity. He described increased popping and buckling of the right knee when going down stairs. He did not report flare-ups. On examination, right knee flexion was to 110 degrees and extension to 0 degrees. Pain was observed on examination but the examiner said it did not cause functional loss. Pain was observed on palpation of the joint. Crepitus was present. The examiner did not indicate the Veteran's ROM after repetitive use over time. The Veteran did not have a history of recurrent effusion of the joint. The examiner noted the meniscal tear and stated that the Veteran had frequent episodes of joint locking and joint pain Private treatment records show that on February 1, 2018, the Veteran had a partial medial meniscectomy. The Veteran had a VA examination in July 2020. He reported increased knee pain and difficulty walking as well as difficulty with movement, pain on movement, and swelling, bilaterally. The Veteran stated that during flare-ups the pain could be sharp and prevent walking. Flare-ups occurred daily, were moderate in degree, and lasted two to three hours. He indicated that he could not take long walks or run due to the knee disability. Testing showed flexion to 65 degrees and extension to 0 degrees. The examiner stated that the decreased ROM led to difficulty walking. Pain was observed and caused functional loss. The Veteran had moderate pain on palpation of the joint. The Veteran did not perform repetitive use testing due to his fear of pain. The examiner estimated that the Veteran's ROM after repetitive use over time and during flare ups would be 60 degrees of flexion and full extension, with pain causing the functional loss. The examiner noted the meniscal tear and the Veteran's frequent episodes of joint "locking." Effusion was not found. The disability interfered with the Veteran's employment as a bus driver and his ability to walk. In this case, the Board finds that a rating greater than 10 percent for limitation of flexion of the right knee is not warranted because at its worst, it was estimated that right knee flexion would be limited to 60 degrees during flare ups and after repeated use over time. A higher rating is not warranted unless the evidence shows flexion limited to 30 degrees or less, with consideration of functional impairment due to pain and other factors. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Here, the July 2020 VA examiner specifically found that functional impairment with consideration of these factors, to include flare-ups, would be 60 degrees. The Board has considered the Veteran's statements describing the impact of his pain and other right knee symptoms on his daily activities and employment; however, the Board finds persuasive the July 2020 examiner's finding that flexion would be limited to 60 degrees. When making the finding, the examiner considered the physical examination, current knee symptoms, and the Veteran's description of his disability during flare-ups. As such, the Board finds that the examiner considered the Veteran's statements in estimating the limitation of flexion during flare-ups and after repetitive use over time, and cannot find that the Veteran's statements alone support a finding that his flexion would be limited to 30 degrees or less. As noted above, the RO changed the Veteran's diagnostic code for the right knee to 38 C.F.R. § 4.71a, Diagnostic Code 5003-5258, for degenerative arthritis rated as dislocated semilunar cartilage, effective July 9, 2020. However, the Board finds that the Veteran should be awarded a separate rating for the meniscal tear and finds that the effective date should be January 26, 2016, the date of the MRI report showing the tear with effusion. With regard to granting a separate rating under Diagnostic Code 5258 when the Veteran is already receiving a rating under Diagnostic Code 5260, VA must avoid pyramiding, i.e., evaluating the same disability under different diagnostic codes or evaluating the same manifestation under different diagnostic codes. 38 C.F.R. § 4.14. VA's general counsel (GC) has issued two opinions indicating that a Veteran who has limitation of motion and instability of the knee may be evaluated separately under separate diagnostic codes provided additional disability is shown. VAOPGCPREC 23-97; 62 Fed. Reg. 63604 (1997); VAOPGCPREC 9-98; 63 Fed. Reg. 56704 (1998). In VAOPGCPREC 9-98, GC found that limitation of motion is a relevant consideration under Diagnostic Code 5259. However, GC has never specifically addressed whether separate ratings for limitation of motion under Diagnostic Codes 5260 or 5261 and for symptoms relating to dislocated or removed semilunar cartilage under Diagnostic Codes 5258 or 5259, including pain, would constitute pyramiding. VA's Adjudication Manual, M211, pt. III, subpt. iv, ch. 4, § A(1)(m), states that evaluations under DCs 5258 and 5259 "can pyramid with evaluations under Diagnostic Codes 5260 or 5261 for limitation of knee flexion or extension. Therefore, separate compensable evaluations are not permitted." VA's Adjudication Manual is not binding on the Board. DAV v. Sec'y of Veterans Affairs, 859 F.3d 1072, 1077 (Fed. Cir. 2017) ("The M21-1 Manual is binding on neither the agency nor tribunals"). Two Court memorandum decisions have held contrary to this Manual provision. See Thaxton v. Shinseki, No. 10-0504, 2011 WL 4525965, at *1 (U.S. Vet. App. Sept. 30, 2011) (mem. dec.) (reversing a Board decision that a separate rating under DC 5259 and DC 5010-5261 would constitute pyramiding); Krause v. Shulkin, No. 16-1213 (Apr. 28, 2017) (reversing Board decision and ordering it to award a separate rating for meniscectomy under Diagnostic Code 5259, even though the Veteran was receiving 10 percent ratings for arthritis and laxity under Diagnostic Codes 5261 and 5257). There are also memorandum decisions holding to the contrary. See Phillips v. Shinseki, No. 12-1044, 2013 U.S. App. Vet. Claims LEXIS 1635 (mem Dec.) ("The appellant argues that the symptoms associated with the removal of semilunar cartilage are '[left knee] pain, decreased range of motion and decreased function.'... The Court is not persuaded that these symptoms are not duplicative of the symptomatology manifested by the arthritis of the left knee that are considered under Diagnostic Code 5003. Thus, the Court agrees with the Secretary that the appellant has not established that the Board erred when it did not award him a separate rating under Diagnostic Code 5259"). See also Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). In the absence of definitive guidance from the Court or GC, and in light of the non-binding nature of VA's Adjudication Manual, the Board finds that under the facts of this case, the symptoms from the Veteran's meniscal tear are sufficiently distinct from those of his residuals of patellofemoral syndrome causing painful limitation of flexion to warrant a separate 20 percent rating for dislocated semilunar cartilage under Diagnostic Codes 5258. With respect to Diagnostic Codes 5259, because the Veteran is now receiving a 20 percent rating under Diagnostic Codes 5258 for symptoms relating to dislocated semilunar cartilage, to compensate him for this as well as removal of symptomatic semilunar cartilage would constitute pyramiding. 38 C.F.R. § 4.71a. Finally, the Board has considered the applicability of other potential diagnostic codes. As the evidence of record fails to demonstrate ankylosis, recurrent subluxation or instability of the knee, limitation of extension, impairment of the tibia or fibula, or genu recurvatum, the Veteran is not entitled to a higher or separate rating under 5256, 5257, 5261, 5262, or 5263, respectively, in the right knee. The Board has considered the Veteran's increased rating claims and decided entitlement based on the evidence. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claims. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for a rating in excess of 10 percent for his right knee limitation of flexion. 38 C.F.R. § 4.71a, Diagnostic Code 5260-5014. However, to the extent that the 10 percent rating is continued from July 9, 2020 to June 2, 2021, the appeal is granted. Further, entitlement to an effective date of January 26, 2016, for the assigment of the separate 20 percent rating under Diagnostic Code 5003-5258 for the right knee meniscal tear is warranted. 38 C.F.R. § 4.71a. However, to the extent that a rating greater than 20 percent is warranted, the appeal must be denied as the Veteran is already in receipt of the highest rating provided under Diagnostic Code 5258. 6. Entitlement to a total rating from June 3, 2021 for right knee total arthroplasty for the one-year period provided under the rating criteria in effect prior to February 7, 2021 is granted. As noted above, the Veteran had a total right knee replacement on June 3, 2021. The RO rated the disability 100 percent from June 3, 2021 and 30 percent from November 1, 2021 under 38 C.F.R. § 4.71a, Diagnostic Code 5055, as revised effective February 7, 2021. In this case, the issue of entitlement for an increased rating for the right knee has been pending since 2011. As such, both the old and revised criteria may be used to rate his disability. Under the rating criteria in effect prior to February 7, 2021, Diagnostic Code 5055 applied only to knee replacement and assigned a 100 percent rating for one year, following implantation of a prosthesis. (The one-year total rating commenced after a one-month convalescent rating under 38 C.F.R. § 4.30). Thereafter, chronic residuals consisting of severe painful motion or weakness in the affected extremity warranted a 60 percent rating. Intermediate degrees of residual weakness, pain, or limitation of motion were rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint was 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020). Effective February 7, 2021, Diagnostic Code 5055 applies to knee replacement and knee resurfacing and assigns a 100 percent rating for 4 months following implantation or prosthesis or resurfacing. A 60 percent rating is assigned for chronic residuals consisting of severe painful motion or weakness in the affected extremity. Intermediate degrees of residual weakness, pain, or limitation of motion are rated by analogy to Diagnostic Codes 5256, 5260, 5261, or 5262. The minimum rating following replacement of a knee joint is 30 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5055. Significantly, the revised criteria limited the total disability rating following knee replacement from one year to 4 months. Clearly the rating criteria in effect prior to the February 7, 2021 revision are more favorable to the Veteran as it provides for a 100 percent rating for one year following implantation of a prosthesis. As such, the Veteran is entitled to the total rating for one year, with consideration of convalescence, as provided under 38 C.F.R. § 4.71a, Diagnostic Code 5055 (2020). To this extent, the appeal is granted. 7. Entitlement to a compensable rating for service-connected hypertension is denied. The Veteran seeks a compensable rating for his hypertension, which is rated under 38 C.F.R. § 4.104, Diagnostic Code 7101. Diagnostic Code 7101 provides a 10 percent rating for evidence showing diastolic pressure of predominately 100 or more; systolic pressure of predominately 160 or more; or as a minimum rating for an individual with a history of diastolic pressure of predominantly 100 or more who requires continuous medication for control. A 20 percent rating is provided for evidence of diastolic pressure of predominantly 110 or more, or systolic pressure predominantly 200 or more. A 40 percent rating is provided for evidence of diastolic pressure of predominantly 120 or more. A 60 percent rating is provided for evidence of diastolic pressure of predominantly 130 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The term "predominant" is not defined in the rating criteria. Merriam-Webster defines predominant to mean "being most frequent or common." See, e.g., "predominant," Merriam-Webster.com Online Dictionary, https://www.merriam-webster.com/dictionary/predominant. For the reasons that follow, the Veteran's hypertension has not more nearly approximated the criteria corresponding to a 10 percent rating. During the October 2011 VA examination, the examiner observed that the Veteran did not have a history of diastolic blood pressure predominantly 100 or more. The blood pressure readings were as follows: 122/74, 126/87, and 124/80. A March 2016 treatment record from Dr. C.F. shows the Veteran's blood pressure was 140/96, uncontrolled. She prescribed medication to treat his hypertension. During his December 2016 hearing before the DRO, the Veteran testified that he took two medications for his hypertension, and that one medication was recently increased. The Veteran was afforded a VA examination in December 2016. The examiner indicated that the Veteran's hypertension was controlled on medication and that he had been taking Micardis for years. He was recently prescribed Amlodipine. The examiner indicated that the Veteran did not have a history of diastolic blood pressure predominantly 100 or more. Blood pressure readings were as follows: 144/86, 142/80, and 138/90. His average blood pressure was 141/85. During his September 2017 hearing before the Board, the Veteran testified that his hypertension had worsened, shown by the prescription of a higher dose of medication and an additional medication. In July 2020, the Veteran had an examination and reported that he had been on several different medications over the past few years to control his hypertension. The examiner indicated that the Veteran's history did not show diastolic blood pressure of predominantly 100 or more. His blood pressure readings were as follows: 150/98, 142/85, and 151/110. The Veteran reported that he had bouts of dizziness and unsteadiness that he believed were related to his hypertension. In addition to the records specifically cited above, the Board also considered blood pressure readings documented in VA treatment records and private treatment records dated since service and throughout the pendency of the claim. Unfortunately, the Veteran's treatment records do not show that he has had a diastolic pressure of predominately 100 or more or has had systolic pressure of predominately 160 or more during the pendency of the claim. Further he does not have a history of diastolic pressure of predominantly 100 or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. Id. The Board acknowledges that the Veteran's diastolic pressure was 110 on one reading in July 2020. However, this is the only reading documenting diastolic pressure at 100 or more. As such, the Veteran's diastolic pressure cannot be found to have been "predominantly" 100 or more; thus, a compensable rating is not warranted based on the examination. Id. Further, while the Veteran takes medication for his hypertension, the Board's review of his blood pressure readings show that his diastolic pressure has been predominantly less than 100. Accordingly, a compensable rating is not warranted based on medications needed for hypertension control. Id. The Board recognizes that a layperson is competent to describe what comes to him or her through the senses. See Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran can assert that his hypertension is worse than currently rated. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). However, to the extent that he asserts that his service-connected hypertension is worse than evaluated, the Board points out that the predominant findings on the VA clinical examinations and treatment records over the years do not establish that he has more severe disability in this respect. As his assertions do not directly address the rating criteria, they do not provide a basis for a higher evaluation. Based on the foregoing, the criteria for a compensable rating for hypertension have not been met, and the appeal is denied. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for dizziness, to include as secondary to service-connected tinnitus and hypertension, is remanded. The Veteran seeks service connection for dizziness. During his DRO hearing, he indicated that his first episode of dizziness coincided with an episode of tinnitus, suggesting a possible nexus between the Veteran's dizziness and service-connected tinnitus. During his September 2017 Board hearing, he testified that he started having dizziness during his last few years of service. Finally, during his July 2020 examination for hypertension, the Veteran reported that he had bouts of dizziness and unsteadiness that he believed were related to his hypertension. An examination has not been provided to determine the etiology of his dizziness, also noted as vertigo and Meniere's disease, and whether the condition is related to service or a service connected disability. On remand, an examination must be scheduled and opinions obtained addressing whether the Veteran's condition is due to service or is due to or has been aggravated by the Veteran's tinnitus, hypertension, or other service-connected disability. 2. Whether new and material evidence has been submitted to reopen the claim for service connection for headaches is remanded. The Veteran seeks service connection for headaches, which he indicated coincided with his episodes of dizziness. See Board hearing transcript at 12. Because a decision on the remanded issue of entitlement to service connection for dizziness could significantly impact a decision on this claim, the issues are inextricably intertwined. A remand of the claim is required. 3. Entitlement to service connection for a right foot disability is remanded. The Veteran seeks service connection for a right foot disability. Service treatment records show the Veteran had pes planus, asymptomatic, at entrance to service. During service, he was treated for painful feet and toes. The July 2004 separation examination documented bilateral pes planus, symptomatic, severe. The Veteran had a VA examination in November 2004; however, the examiner found that the Veteran's feet were normal and asymptomatic. Since that time, the Veteran has reported continued right foot pain. Significantly, the October 2013 VA examination shows reports of painful feet, with the right foot being worse than the left. The examiner diagnosed plantar fasciitis. The examiner did not indicate whether the condition was related to service. Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). Such conditions are considered to be pre-existing. When a pre-existing disorder is noted on entry, a veteran has the burden of showing that it is at least as likely as not that the disorder increased in severity during service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). If a veteran meets that burden and shows that an increase in severity occurred, the burden then shifts to VA to show whether such increase is clearly and unmistakably due to the natural progression of the pre-existing disability rather than due to service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231, 235 (2012); C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). On remand, an examination must be scheduled to identify all right foot disabilities. The examiner must then provide an opinion indicating whether the Veteran continues to have pes planus, or flat feet, and if so, whether the disability worsened during service, and if so, whether such increase is clearly and unmistakably due to the natural progression of the pre-existing disability rather than due to service. The examiner must also provide an opinion indicating whether the plantar fasciitis identified in October 2013, and any other right foot disability identified during the pendency of the claim, is related to the Veteran's service. The examiner must specifically address the in-service treatment of his feet and toes. Finally, if the examiner finds that the Veteran has pes planus and that it worsened during service due to service, then the examiner should indicate whether pes planus caused or aggravated the plantar fasciitis or other identified right foot disabilities. 4. Entitlement to service connection for chest pain other than costochondritis, to include as secondary to service-connected hypertension, is remanded. The Veteran seeks service connection for chest pain other than costochondritis, to include as secondary to his service-connected hypertension. An August 2009 VA treatment record notes the Veteran's report of pressure and heavy chest pain in the morning under cardiovascular. The assessment was atypical chest pain. The Veteran had a follow-up for the chest pain in August 2011. A VA examination has not been provided to determine the etiology or underlying pathology of the Veteran's chest pain other than costochondritis. On remand, the Veteran must be afforded an examination to determine whether he has chest pain other than costochondritis that is related to service or is due to or has been aggravated by his service-connected hypertension. 5. Entitlement to a rating greater than 10 percent for residuals of right elbow fracture with retained hardware is remanded. 6. Entitlement to a compensable rating for limitation of extension of the right elbow is remanded. The Veteran seeks increased ratings for his right elbow disability. He has a 10 percent rating for right elbow fracture, rated under 38 C.F.R. § 4.71a, Diagnostic Code 5206, forearm, limitation of flexion. He also has a separate noncompensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5207, forearm, limitation of extension. Unfortunately, these matters must be remanded for additional development because the October 2011 and December 2016 VA examination reports are inadequate for rating purposes. The October 2011 examination report is inadequate for rating purposes because the examiner did not measure the ROM for both elbows or address pain on active and passive motion. See Correia v. McDonald, 28 Vet. App. 158 (2016). Further, the examiner noted that the findings were questionable and did not provide estimates of ROM after repetitive use or during flare up. Therefore, the examination report cannot be used for rating purposes. The Veteran had another examination in December 2016; however, this examination report is also inadequate for rating purposes. Specifically, the examiner did not obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veteran. Sharp v. Shulkin, 29 Vet. App. 26 (2017). On remand, an examination of the right elbow must be scheduled to determine the current severity of the disability. 7. Entitlement to a TDIU is remanded. Finally, because a decision on the remanded issues above could significantly impact a decision on the issue of entitlement to a TDIU, the issues are inextricably intertwined. A remand of the claim for a TDIU is required. The matters are REMANDED for the following actions: 1. Associate with the claims file updated VA treatment records. 2. Then, schedule the Veteran for a VA examination for dizziness. The examiner must be provided access to the electronic claims file and indicate review of the file in the examination report. The examiner should identify any disability manifesting as dizziness. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. For any diagnosis of, or related to, dizziness, to include vertigo and Meniere's disease, the examiner is asked to provide a response to the following: Is the disability at least as likely as not (50 percent or greater probability) related to service? Is the disability at least as likely as not proximately due to service-connected tinnitus and/or hypertension? Is the disability at least as likely as not aggravated by service-connected tinnitus or hypertension? Separate opinions with rationale should be provided for each opinion requested. The examiner is reminded that for aggravation, any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation/worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). 3. Schedule the Veteran for a VA examination for his right foot disability. The examiner must be provided access to the electronic claims file and indicate review of the file in the examination report. The examiner should identify all right foot disabilities. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. A. For pes planus, which was documented at entrance to and separation from service, has the Veteran continued to have pes planus during the pendency of the claim? (a) If so, did the Veteran's pes planus, which existed prior to service, at least as likely as not (50 percent or greater probability) increase in severity during service? (b) If so, was the increase in severity clearly and unmistakably (undebatable) due to the natural progress of the disease? B. For any other identified right foot disability, to include plantar fasciitis as noted in the October 2013 VA examination, is the disability at least as likely as not (50 percent or greater probability) related to service, to include his in-service treatment for painful feet and toes? C. If the examiner finds that the Veteran continues to have pes planus, finds that pes planus increased in severity during service, and finds that the increase is not due to the natural progress of the disease, then for each right foot disability, provide a response to the following: (a) Is the disability at least as likely as not (50 percent or greater probability) proximately due to pes planus? (b) Is the disability at least as likely as not (50 percent or greater probability) aggravated, by pes planus? Separate opinions with rationale should be provided for each opinion requested. The examiner is reminded that for aggravation, any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation/worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). 4. Then, schedule the Veteran for a VA examination for chest pain other than costochondritis. The examiner must be provided access to the electronic claims file and indicate review of the file in the examination report. The examiner should identify any disability manifesting as chest pain other than costochondritis. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. For any diagnosis of, or related to, chest pain, other than costochondritis, the examiner is asked to provide a response to the following: Is the disability at least as likely as not (50 percent or greater probability) related to service? Is the disability at least as likely as not (50 percent or greater probability) proximately due to service-connected hypertension? Is the disability at least as likely as not (50 percent or greater probability) aggravated by service-connected hypertension? Separate opinions with rationale should be provided for each opinion requested. The examiner is reminded that for aggravation, any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation/worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). 5. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected right elbow disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 6. Then, readjudicate the Veteran's claims on appeal, to include the claims pertaining to TDIU and headaches. If the benefits sought on appeal remain denied, provide the Veteran and his representative a supplemental statement of the case and allow an appropriate period for response. L. CHU Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. G. Alderman, 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.