Citation Nr: 21073138 Decision Date: 12/07/21 Archive Date: 12/07/21 DOCKET NO. 13-25 391A DATE: December 7, 2021 ORDER Service connection for eczema is granted. An increased initial disability rating in excess of 60 percent, but no higher, for service-connected hypothyroidism is granted. An increased initial disability rating in excess of 10 percent for service-connected right knee disability is denied. An increased initial disability rating in excess of 10 percent for service-connected left knee disability is denied. From September 27, 2016, an initial disability rating of 20 percent, but no higher, for right knee lateral instability is granted. From September 27, 2016, an initial disability rating of 20 percent, but no higher, for left knee lateral instability is granted An initial compensable disability rating of 10 percent, but no higher, for service-connected right shin splints is granted. An initial compensable disability rating of 10 percent, but no higher, for service-connected left shin splints is granted. Prior to June 22, 2017, an increased initial disability rating in excess of 30 percent for service-connected depression is denied. From June 22, 2017, and increased disability rating of 70 percent, but no higher, for service-connected depression is granted. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, her eczema began during active service. 2. Resolving reasonable doubt in the Veteran's favor, during the claim period, the Veteran's hypothyroidism exhibited symptoms more closely associated with fatiguability, mental disturbance, and weight gain, but not muscular weakness, sleepiness, cardiovascular involvement, or bradycardia. 3. During the claim period, the Veteran's right knee disability did not exhibit flexion limited to 30 degrees or less, or extension limited to 15 degrees or more. 4. During the claim period, the Veteran's left knee disability did not exhibit flexion limited to 30 degrees or less, or extension limited to 15 degrees or more. 5. Resolving reasonable doubt in the Veteran's favor, from September 27, 2016, the Veteran's right knee exhibited moderate lateral instability. 6. Resolving reasonable doubt in the Veteran's favor, from September 27, 2016, the Veteran's left knee exhibited moderate lateral instability. 7. During the claim period, the Veteran's right shin splints exhibited malunion of the tibia and fibula with slight ankle disability. 8. During the claim period, the Veteran's left shin splints exhibited malunion of the tibia and fibula with slight ankle disability. 9. Prior to June 22, 2017, the Veteran's depression did not result in occupational and social impairment with reduced reliability and productivity. 10. Resolving reasonable doubt in the Veteran's favor, from June 22, 2017, the Veteran's depression resulted in occupational and social impairment, with deficiencies in most areas, and not total social and occupational impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for eczema are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for an initial disability rating of 60 percent, but no higher, for hypothyroidism are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.119, Diagnostic Code 7903 (in effect prior to December 10, 2017). 3. The criteria for a rating in excess of 10 percent for a right knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5260 and 5261. 4. The criteria for a rating in excess of 10 percent for a left knee disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes 5260 and 5261. 5. From September 27, 2016, the criteria for an initial disability rating of 20 percent, but no higher, for right knee lateral instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (in effect prior to February 7, 2021). 6. From September 27, 2016, the criteria for an initial disability rating of 20 percent, but no higher, for left knee lateral instability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5257 (in effect prior to February 7, 2021). 7. The criteria for an initial disability rating of 10 percent, but no higher, for right shin splints are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5262 (in effect prior to February 7, 2021). 8. The criteria for an initial disability rating of 10 percent, but no higher, for left shin splints are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5262 (in effect prior to February 7, 2021). 9. Prior to June 22, 2017, the criteria for an increased initial disability rating in excess of 30 percent for depression have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9435. 10. From June 22, 2017, the criteria for an increased disability rating of 70 percent, but no higher, for depression are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9435. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from September 1996 until her honorable discharge in June 2011. She served in Iraq from June 2003 to April 2004, November 2004 to December 2005, September 2008 to February 2009, and from March 2010 to February 2011. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision by a Regional Office of the United States Department of Veterans Affairs (VA). In February 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. In May 2018 and November 2020, the Board remanded the claims to the VA Regional Office for further development. Within each respective remand order, the Board directed the VA Regional Office to, among other things, obtain new VA medical examinations and opinions addressing the Veteran's claimed disabilities. The VA Regional Office accomplished the Board's directives. The case now returns to the Board for adjudication. Evidentiary Standards In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits and when rating disabilities. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (service connection); 38 C.F.R. § 4.3 (disability rating). To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). The law requires the Board address its reasons for rejecting evidence favorable to the Veteran. Timberlake v. Gober, 14 Vet. App. 122, 12829 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claims. Service Connection VA provides compensation for a disability resulting from disease or injury incurred in or aggravated by service. This is referred to as a "service connection." 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to be entitled to service connection there must be competent, credible evidence of (1) a current disability, (2) an in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). When these elements are satisfied, service connection may be granted on a direct basis. 1. Service connection for eczema is granted. First element: A current disability The requirement for a veteran to have a "current disability" is satisfied when he or she has a disability (1) at the time a claim for VA disability compensation is filed or (2) has a disability during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The Veteran has received numerous medical examinations to assess whether she has or has had eczema during the claim period. The first exam occurred in July 2011. That examiner diagnosed the Veteran with rosacea and specifically excluded eczema. Nonetheless, the Veteran's medical records indicated a subsequent diagnosis of eczema on her ears in January and June 2012. In June 2017, an examiner only diagnosed the Veteran with rosacea. In May 2018, an examiner diagnosed the Veteran with dermatitis eczema on her ears. In February 2021, an examiner only diagnosed the Veteran with rosacea. The Board notes the Veteran is service connected for rosacea. Because the Veteran has had a formal diagnosis of eczema at various points during the claim period, the Board concludes that the requirements for a "current disability" are satisfied. Second element: An in-service event, injury, or illness, or aggravation thereof Due to her service in Iraq, the Veteran asserts exposure to various environmental hazards. More important to the Board's decision on this issue, the Veteran testified at her February 2018 Board hearing that during her active military service, she experienced flaky skin around her ears, which happens to be the location of her current eczema. Associated with her condition, she experienced fluid profusion out of her ears and excessive itching. She testified that she sought in-service medical treatment but was told there was nothing wrong with her ears. During her 2011 separation examination, she reported experiencing skin diseases in service, but the medical examiner did not diagnose her with a skin disease at that time. The Board finds the Veteran's statement credible and probative. Based on the evidence of record, the Board is satisfied that an in-service event or onset of a skin disease, to include eczema, exists. Therefore, the second element is satisfied. Third element: A causal link The VA Regional Office obtained two opinions addressing the etiology of the Veteran's eczema. A February 2018 examiner opined that the Veteran's eczema was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because there was no objective evidence of a chronic condition. The Board previously found this opinion and rational insufficient in its November 2020 Remand Order as it was unaccompanied by any explanation of why there was no chronic condition and a lack of discussion of the evidence of record indicting eczema since service. In a February 2021 addendum opinion, a separate examiner opined that the Veteran's eczema was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because there was no current diagnosis of eczema on examination and "[t]here is no evidence found in the [in-service medical records] to support a diagnosis of eczema or associated treatments for this condition." The Board finds this opinion is insufficient because it is conclusory and did not consider the Veteran's lay statements from her February 2018 Board hearing regarding the onset of her skin condition. Furthermore, the examiner stated that the Veteran's symptoms were "subjective only" and offered no explanation as to why her subjective statements were not medically credible. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that an examiner's opinion relying on the absence of contemporaneous medical evidence "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim of service connection could be proven"). Therefore, the Board finds there is no adequate medical opinion of record addressing the etiology of the Veteran's eczema. Despite the absence of an adequate medical opinion, the Board finds the evidence of record reasonably supports a causal link between the Veteran's service and her eczema. First, the Board observes that during the Veteran's 1996 enlistment examination, the medical evaluator did not document any skin conditions. Thus, she is presumed to have been sound on entry. 38 U.S.C. § 1111 ("[E]very veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment[.]"). Second, the Veteran has credibly testified that she experienced an onset of eczema in service, and she reported skin issues at the time of her separation in 2011. Third, she has intermittently experienced eczema since service. The Board finds that her eczema was continuous despite periods of inactivity. There is no credible evidence in the record that indicates it was not a continuous condition just because it was not present at every medical examination. Rather, her eczema "comes and goes." According to Savage v. Gober, 10 Vet. App. 488, 497 (1997), lay evidence of continuing symptoms of a disability following service can be sufficient to demonstrate a medical nexus between a current disability and an in-service event or injury, even where there is no medical opinion establishing that nexus. The Board finds this is such an instance. The Veteran's credible statements and testimony, when coupled with her military and medical records, sufficiently demonstrate a continuity of symptoms of eczema since service, and there is no evidence of an intervening injury, illness, or event. Resolving reasonable doubt in the Veteran's favor, the third element is satisfied. Accordingly, service connection for eczema is granted. Increased Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities found in 38 C.F.R. Part 4. The Schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Diagnostic codes are assigned to individual disabilities. Diagnostic codes provide rating criteria specific to a particular disability. If two diagnostic codes are applicable to the same disability, the diagnostic code that allows for the higher disability rating applies. 38 C.F.R. § 4.7. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Id. An initial rating is one assigned at the time service-connection is granted. Generally, the effective date of an initial rating is the date of receipt of the claim or request or the date entitlement arose, whichever is later. 38 U.S.C.§ 5110(a); 38 C.F.R. § 3.400(o)(1); see Sutton v. Nicholson, 20 Vet. App. 419, 422 (2006). When an initial rating decision is on appeal, evidence contemporaneous with the claim and with the initial rating decision granting service connection would be most probative of the degree of disability existing at those times and should be the evidence used to decide whether an original rating was erroneous. Fenderson v. West, 12 Vet. App. 119, 126 (1999). In this case, all of the Veteran's claims for increased disability ratings stem from initial ratings assigned by the VA Regional Office. Separate ratings can be assigned for separate periods of time based on the facts founda practice known as "staged" ratings. Id. A staged rating is a rating that looks backwards and retroactively assigns specific ratings to discrete periods. See Reizenstein v. Shinseki, 583 F.3d 1331, 1337 (Fed. Cir. 2009). This practice accounts "for the possible dynamic nature of a disability while the claim works its way through the adjudication process." O'Connell v. Nicholson, 21 Vet. App. 89, 93 (2007); see also 38 C.F.R. § 4.1. The effective date for a staged rating is when it is factually ascertainable that a particular rating is warranted. Hart v. Mansfield, 21 Vet. App. 505, 509 (2007). In cases where staged ratings are appropriate, it is necessary to consider all "the evidence of record from the time of the veteran's application." Fenderson, 12 Vet. App. at 127. 2. An increased initial disability rating in excess of 60 percent, but no higher, for service-connected hypothyroidism is granted. Rating Criteria Hypothyroidism The Veteran's service-connected hypothyroidism is rated under 38 C.F.R. § 4.119, Diagnostic Code 7903. As of December 10, 2017, VA enacted new rating criteria for Diagnostic Code 7903. See Schedule for Rating Disabilities: Endocrine System, 82 Fed. Reg. 50,804 (Nov. 2, 2017). Because the Veteran's claim for an increased disability rating has been pending since she filed her initial claim for service connection in 2011, the Board is required to analyze her claim under each version of Diagnostic Code 7903 from December 10, 2017, onward, and which ever version provides her the greater benefit will be applied from that point. See Ervin v. Shinseki, 24 Vet. App. 318 (2011) (discussing retroactivity and effects of changes in law or regulation during the pendency of an appeal), opinion corrected, 25 Vet. App. 178 (2012). Prior to December 10, 2017, 38 C.F.R. § 4.119, Diagnostic Code 7903, provided: Rating (%) Cold intolerance, muscular weakness, cardiovascular involvement, mental disturbance (dementia, slowing of thought, depression), bradycardia (less than 60 beats per minute), and sleepiness 100 Muscular weakness, mental disturbance, and weight gain 60 Fatigability, constipation, and mental sluggishness 30 Fatigability, or; continuous medication required for control 10 The use of the term "and" within this rating criteria indicates that the Veteran's hypothyroidism must display each listed symptom to receive the associated rating, not one or another. See Middleton v. Shinseki, 727 F.3d 1172, 1178 (Fed. Cir. 2013) (noting that the "use of the conjunction 'and' . . . necessitates" all elements must be met). Whereas use of the term "or" indicates only one of the symptoms must be established rather than all symptoms. See Bonny v. Principi, 16 Vet. App. 504, 507 (2002) (stating that using the conjunction "or" indicates that separate phrases state substantive alternatives). From December 10, 2017, 38 C.F.R. § 4.119, Diagnostic Code 7903 provides: Rating (%) Hypothyroidism manifesting as myxedema (cold intolerance, muscular weakness, cardiovascular involvement (including, but not limited to hypotension, bradycardia, and pericardial effusion), and mental disturbance (including, but not limited to dementia, slowing of thought and depression)). 100 Note (1): This evaluation shall continue for six months beyond the date that an examining physician has determined crisis stabilization. Thereafter, the residual effects of hypothyroidism shall be rated under the appropriate diagnostic code(s) within the appropriate body system(s) (e.g., eye, digestive, and mental disorders). Hypothyroidism without myxedema 30 Note (2): This evaluation shall continue for six months after initial diagnosis. Thereafter, rate residuals of disease or medical treatment under the most appropriate diagnostic code(s) under the appropriate body system (e.g., eye, digestive, mental disorders). Note (3): If eye involvement, such as exophthalmos, corneal ulcer, blurred vision, or diplopia, is also present due to thyroid disease, also separately evaluate under the appropriate diagnostic code(s) in § 4.79, Schedule of Ratings - Eye (such as diplopia (diagnostic code 6090) or impairment of central visual acuity (diagnostic code 6061-6066)). There is no disability rating lower than 30 percent under the current version of Diagnostic Code 7903. In every instance where the Rating Schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The use of the term "and" within this rating criteria indicates that the Veteran's hypothyroidism must display both myxedema and mental disturbance, not one or the other, in order to receive a 100 percent disability rating. See Middleton, 727 at 1178. Analysis Prior to December 10, 2017 The VA Regional Office assigned the Veteran an initial disability rating of 30 percent in the May 2012 rating decision, which used the criteria prior to December 10, 2017. The VA Regional Office found the Veteran's hypothyroidism manifested as fatiguability and mental sluggishness, and it also required continuous medication for control. The Veteran has received multiple examinations during the claim period assessing the severity of her hypothyroidism. First, in July 2011, an examiner recorded the Veteran's symptoms included weight gain, swelling in her hands and feet, some hair loss, cold intolerance, fatigue, and mental sluggishness, but not chronic constipation. Second, she received an examination in June 2017. That examiner recorded that she was still on medication to control her thyroid. The examiner attributed symptoms of depression, irritation, weight gain, tingling of the hands and feet, and puffiness to her hypothyroidism. The examiner recorded a normal heartbeat, blood pressure, and muscle reflexes. The examiner stated that the Veteran's symptoms were not consistent with myxedema. Based on her lab results, she was "euthyroid" (having a normally functioning thyroid gland) and "not expected . . . to have clinical symptoms." On review of the Veteran's medical records, the Board is unable to locate credible evidence that she experienced symptoms of constipation, muscular weakness, cardiovascular involvement, bradycardia (less than 60 beats per minute), or sleepiness, associated with her hypothyroidism. The Board acknowledges that the Veteran is service connected for various musculoskeletal disabilities, however, none of those disabilities are associated with her hypothyroidism. None of her medical providers have credibly indicated, or reasonably suggested, that those musculoskeletal disabilities were caused or exacerbated by her hypothyroidism. During her February 2018 Board hearing, the Veteran was questioned about whether her doctors have associated her muscle weakness with her hypothyroidism, and she testified they had not. February 2018 Board Hearing Transcript, at 13. Absent credible medical evidence connecting those disabilities to her hypothyroidism, the Board finds a lack of evidence of symptoms of muscle weakness. See Fagan v. Shinseki, 573 F.3d 1282, 1286 (2009) (stating that the claimant has the burden to "present and support a claim for benefits" and noting that the benefit of the doubt standard in [38 U.S.C. §] 5107(b) is not applicable based on pure speculation or remote possibility). The Board acknowledges the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran if the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). While the Board finds the Veteran competent to report symptoms of muscle weakness, without evidence showing that she has the necessary medical training or expertise, she cannot competently opine that any muscle weakness is due to her hypothyroidism. See 38 C.F.R. § 3.159(a)(1), (2); Jandreau v. Nicholson, 493 F.3d 1372, 1377 (Fed. Cir. 2007) (noting general competence of lay persons to testify as to symptoms but not medical diagnosis). Of relevant note here is the difference between "mental disturbance" and "mental sluggishness." Diagnostic Code 7903, both prior to and as of December 10, 2017, specifies that a mental disturbance includes dementia, slowing of thought, and depression. The Veteran's medical records document that her depression and hypothyroidism are reasonably associated. The Board finds her depression more closely aligns with a mental disturbance rather than mental sluggishness. Despite the fact that the Veteran's hypothyroidism did not manifest as all of the symptoms associated with the 60 percent rating criteria under Diagnostic Code 7903, this does not prevent the Board from awarding a higher disability rating. Under 38 C.F.R.§ 4.7, the Board has discretion to award a higher rating, despite not all of the criteria being satisfied, "if the disability picture more nearly approximates the criteria required for that rating." See also Tatum v. Shinseki, 23 Vet. App. 152 (2009) (a higher rating may be awarded under Diagnostic Code 7903 even if all of the criteria are not satisfied if disability picture more nearly approximates the criteria required for that rating) (citing 38 C.F.R. § 4.7). Prior to December 10, 2017, the Veteran's symptoms included cold intolerance, weight gain, mental disturbance, fatiguability, and continuous medication. The Board finds that the Veteran's hypothyroidism more closely resembled the 60 rating criteria rather than the 30 percent rating criteria. The Board finds that a 100 percent disability rating is not warranted because the Veteran's hypothyroidism did not manifest as muscular weakness, sleepiness, cardiovascular involvement, or bradycardia (less than 60 beats per minute). Thus, her hypothyroidism did not more closely resemble the criteria associated with a 100 percent disability rating. From December 10, 2017 The Veteran received a May 2018 and a February 2021 examination assessing her hypothyroidism. The May 2018 examiner recorded symptoms including irritability, sleepiness, and the use of medications. There was a lack of evidence indicating symptoms involving the musculoskeletal system or cardiovascular system. The examiner found that the Veteran did have hypoactive reflexes. The February 2021 examiner documented that the Veteran did not exhibit symptoms during the examination associated with her hypothyroidism. This was most likely due to her medication. Her physical examination, to include muscle reflexes, was normal. On review of the Veteran's medical records from December 10, 2017, the Board is unable to locate credible evidence that the Veteran's hypothyroidism displayed symptoms associated with her musculoskeletal system or cardiovascular system. The Board has considered whether the Veteran would benefit from the application of the prior version of Diagnostic Code 7903 or the current version of Diagnostic Code 7903 as of December 10, 2017. The Board concludes that the application of the prior version of Diagnostic Code 7903 benefits the Veteran more than the current version. Under the current version, the Board finds that the evidence does not more closely resemble the criteria associated with the 100 percent rating. Namely, the Veteran's hypothyroidism did not manifest as myxedema, including muscular weakness or cardiovascular involvement. Moreover, the more recent examinations showed that the Veteran's symptoms have subsided, and her hypothyroidism did not display any of the symptoms associated with the 100 percent disability rating criteria. Even when applying the prior version of Diagnostic Code 7903, she would not be entitled to a 100 percent disability rating for the same reasons. Nonetheless, by applying the version of Diagnostic Code 7903 in effect prior to December 10, 2017, the Veteran will retain her 60 percent initial disability rating. Accordingly, applying 38 C.F.R. § 4.119, Diagnostic Code 7903 (in effect prior to December 10, 2017), the Veteran is entitled to an initial 60 percent disability rating, but no higher, for her hypothyroidism. 3. An increased initial disability rating in excess of 10 percent for service-connected right knee disability is denied. 4. An increased initial disability rating in excess of 10 percent for service-connected right knee disability is denied. The Board addresses the Veteran's right and left knee disabilities together as there is a substantial overlap in their legal analyses. Rating Criteria Knee (arthritis) The Veteran is service connected for right and left knee degenerative joint disease (arthridity). Degenerative arthritis is rated under 38 C.F.R. § 4.71a, DC 5003, which provides: Rating (%) Arthritis, degenerative (hypertrophic or osteoarthritis): Degenerative arthritis established by X-ray findings will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved (DC 5200 etc.). When however, the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, 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. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm, or satisfactory evidence of painful motion. In the absence of limitation of motion, rate as below: With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups, with occasional incapacitating exacerbations 20 With X-ray evidence of involvement of 2 or more major joints or 2 or more minor joint groups 10 Note (1): The 20 [percent] and 10 [percent] ratings based on X-ray findings, above, will not be combined with ratings based on limitation of motion. Note (2): The 20 [percent] and 10 [percent] ratings based on X-ray findings, above, will not be utilized in rating conditions listed under diagnostic codes 5013 to 5024, inclusive. For the purpose of rating arthritis, "major joints" include the shoulder, elbow, wrist, hip, knee, and ankle. 38 C.F.R. § 4.45(f). "Minor joints" include "multiple involvements of the interphalangeal, metacarpal and carpal joints of the upper extremities, the interphalangeal, metatarsal and tarsal joints of the lower extremities, the cervical vertebrae, the dorsal vertebrae, and the lumbar vertebrae." Id. In reference to the limitation of motion of the knee, VA regulations provide two specific Diagnostic Codes, 5260 (limitation of flexion) and 5261 (limitation of extension). This does not limit the Board from considering separate ratings for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of, or overlapping with, the symptomatology of the other condition. Esteban v. Brown, 6 Vet. App. 259 (1994). The assignment of separate ratings requires separately compensable symptomatology. See VAOPGCPREC 9-04. VA General Counsel precedential opinions are binding on the Board. 38 U.S.C. § 7104(c); 38 C.F.R. § 14.507. Diagnostic Code 5260 provides: Rating (%) Leg, limitation of flexion of: Flexion limited to 15° 30 Flexion limited to 30° 20 Flexion limited to 45° 10 Flexion limited to 60° 0 Full knee flexion is 140 degrees for VA rating purposes. 38 C.F.R. § 4.71, Plate II. Diagnostic Code 5261 provides: Rating (%) Leg, limitation of extension of: Extension limited to 45° 50 Extension limited to 30° 40 Extension limited to 20° 30 Extension limited to 15° 20 Extension limited to 10° 10 Extension limited to 5° 0 Full knee extension is 0 degrees for VA rating purposes. 38 C.F.R. § 4.71, Plate II. In addition, when VA evaluates musculoskeletal disabilities under the Rating Schedule, it must determine whether or not the factors listed in 38 C.F.R. §§ 4.40, 4.45, and 4.59 are properly accounted for within the applicable diagnostic criteria. Under section 4.40, VA must consider whether there is evidence of functional loss due to pain on movement and diminished excursion, strength, speed, coordination, and endurance, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.40; Mitchell v. Shinseki, 25 Vet. App. 32, 43 (2001). Pain on movement, standing alone, is not sufficient to warrant a higher rating under section 4.40. Id. (reaffirming that pain must affect some aspect of "the normal working movements of the body . . . in order to constitute functional loss"). Section 4.45 expands upon the concept of functional loss, noting six factors that VA must consider when evaluating a disability, namely: (1) less or (2) more movement than is normal; (3) weakened movement; (4) excess fatigability; (5) incoordination; and (6) pain on movement (as well as swelling, deformity, and atrophy) that affects stability, standing, and weight-bearing, to include during flare-ups or after repetitive use. 38 C.F.R. § 4.45. Noticeably, the aspects of functional loss listed in section 4.40 closely parallel the factors listed in section 4.45. Section 4.45 applies to muscles, nerves, as well as the entire musculoskeletal system. DeLuca v. Brown, 8 Vet. App. 202, 207 (1995). Under section 4.59, a veteran may be awarded the minimum compensable evaluation available under a given musculoskeletal diagnostic code, even if application of that code would not support a compensable evaluation, where there is evidence of "actually painful, unstable, or malaligned joints." 38 C.F.R. § 4.59; Petitti v. McDonald, 27 Vet. App. 415, 427 (2015). Section 4.59 does not require medical evidence; it may be satisfied with lay and other non-medical evidence. Id. at 428. Thus, pain alone is compensable under section 4.59 for joint disabilities in general. Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Analysis Right Knee The VA Regional Office assigned an initial disability rating of 10 percent for the Veteran's right knee arthritis based on painful motion under 38 C.F.R. § 4.59 because neither her right knee flexion nor extension met the compensable rating criteria. The Veteran has received multiple examinations to assess the severity of her right knee arthritis. The Board discusses each in turn. In July 2011, a VA examiner documented that the Veteran's right knee had flexion limited to 130 degrees and full extension (0 degrees). There was pain on active motion and weightbearing. That examination was inadequate under the current law because it failed to address loss of ranges of motion on flare-ups or following repetitive use as required by 38 C.F.R. §§ 4.40 and 4.45. Nonetheless, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. See Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (inadequate medical opinion can still have probative value). In June 2017, a VA examiner documented that that Veteran's right knee had full flexion (140 degrees) and full extension (0 degrees). There was no functional loss after observed repetitive use. The examiner did not offer an estimation of any range-of-motion loss following repetitive use over time, only stating that it would be speculation. The Veteran did not report experiencing flare-ups. Pain was observed on non-weightbearing and weightbearing. The Board found this examination inadequate in its May 2018 Remand Order because the examiner offered no basis for being unable to provided estimated range-of-motion loss following repetitive use. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017) (if the examiner cannot provide an opinion as to additional loss of motion without resorting to mere speculation, the examiner must make clear that he has considered all procurable data). Nonetheless, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. Consequently, the Veteran received a VA-contracted examination in May 2018. The examiner documented right knee flexion limited to 120 degrees and full extension (0 degrees). There was no additional loss of range of motion following observed repetitive use. Although the Veteran reported flare-ups, the examiner did not offer an opinion about additional loss of range of motion during flare-ups or following repetitive use over time because the examiner found it would be speculation. The examiner's reasoning for being unable to provide such opinions was inadequate and not consistent with Sharp, 29 Vet. App. at 33. Nonetheless, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. The VA Regional Office obtained another VA-contracted examination in July 2020. The examiner documented full flexion (140 degrees) and extension (0 degrees) of the right knee. There was no additional loss of range of motion following observed repetitive use. The examiner opined that following repetitive use over time and during flare-ups, the Veteran would experience limitation of flexion to 135 degrees and no limitation of extension. Pain was noted on passive and non-weightbearing testing. The Veteran received a final VA-contracted examination in February 2021. The examiner documented full flexion (140 degrees) and extension (0 degrees) of the right knee. There was no additional loss of range of motion following observed repetitive use. The examiner opined that following repetitive use over time, the Veteran would experience limitation of flexion to 130 degrees and no limitation of extension. The examiner opined the Veteran would not experience additional loss of range of motion during flare-ups. Pain was noted on passive and weightbearing testing. Based on all of the Veteran's VA and VA-contracted medical examinations addressing his right knee limitation of motion, the Board finds that no examiner documented compensable limitation of flexion (at least 45 degrees) or compensable limitation of extension (at least 10 degrees). At most, the Veteran's right knee displayed flexion limited to 120 degrees and full extension (0 degrees). On review of the Veteran's medical records, the Board finds relevant medical records documenting the Veteran's right knee range of motion. In a December 2015 VA Orthopedic Surgery Consult, a VA orthopedic surgeon documented right knee flexion limited to 100 degrees and full extension (0 degrees). In December 2017 and June 2018 VA Orthopedic Surgery Notes, an orthopedic surgeon documented right knee flexion limited to 90 degree and full extension (0 degrees) on each date. None of the Veteran's medical records document that her right knee displayed compensable limitations of flexion or extension. Based on the evidence of record, the Board finds that the Veteran's right knee flexion or extension did not manifest to a compensable degree of limitation during the claim period. At most, the Veteran's flexion was limited to 90 degrees, a noncompensable limitation, and she only displayed full extension. Therefore, her current assigned disability rating of 10 percent based on pain and limitation of motion under 38 C.F.R. § 4.59 is appropriate. She is not entitled to a higher disability rating for her right knee arthritis. Left Knee The VA Regional Office assigned an initial disability rating of 10 percent for the Veteran's left knee arthritis based on painful motion under 38 C.F.R. § 4.59 because neither her left knee flexion nor extension met the compensable rating criteria. The Veteran has received multiple examinations to assess the severity of her left knee arthritis. The Board discusses each in turn. In July 2011, a VA examiner documented that the Veteran's left knee had flexion limited to 130 degrees and full extension (0 degrees). There was pain on active motion and weightbearing. That examination was inadequate under the current law because it failed to address loss of ranges of motion on flare-ups or following repetitive use as required by 38 C.F.R. §§ 4.40 and 4.45. Nonetheless, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. In June 2017, a VA examiner documented that that Veteran's left knee had full flexion (140 degrees) and full extension (0 degrees). There was no functional loss after observed repetitive use. The examiner did not offer an estimation of any range-of-motion loss following repetitive use over time, only stating that it would be speculation. The Veteran did not report experiencing flare-ups. Pain was observed on non-weightbearing and weightbearing. While this examination was not compliant with 38 C.F.R. § 4.40 and 4.45 under Sharp, 29 Vet. App. at 33, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. In May 2018, a VA-contracted examiner documented left knee flexion limited to 130 degrees and full extension (0 degrees). There was no additional loss of range of motion following observed repetitive use. Although the Veteran reported flare-ups, the examiner did not offer an opinion about additional loss of range of motion during flare-ups or following repetitive use over time because the examiner found it would be speculation. The examiner's reasoning for being unable to provide such opinions was inadequate and not consistent with Sharp, 29 Vet. App. at 33. Nonetheless, the ranges of motion documented by the examiner are still credible and probative as they were appropriately conducted. The VA Regional Office obtained another VA-contracted examination in July 2020. The examiner documented full flexion (140 degrees) and extension (0 degrees) of the left knee. There was no additional loss of range of motion following observed repetitive use. The examiner opined that following repetitive use over time and during flare-ups, the Veteran would experience limitation of flexion to 135 degrees and no limitation of extension. Pain was noted on passive and non-weightbearing testing. The Veteran received a final VA-contracted examination in February 2021. The examiner documented full flexion (140 degrees) and extension (0 degrees) of the left knee. There was no additional loss of range of motion following observed repetitive use. The examiner opined that following repetitive use over time, the Veteran would experience limitation of flexion to 130 degrees and no limitation of extension. The examiner opined the Veteran would not experience additional loss of range of motion during flare-ups. Pain was noted on passive and weightbearing testing. Based on all of the Veteran's VA and VA-contracted medical examinations addressing her left knee limitation of motion, the Board finds that no examiner documented compensable limitation of flexion (at least 45 degrees) or compensable limitation of extension (at least 10 degrees). At most, the Veteran's left knee displayed flexion limited to 130 degrees and full extension (0 degrees). On review of the Veteran's medical records, the Board finds relevant medical records documenting the Veteran's right knee range of motion. In a December 2015 VA Orthopedic Surgery Consult, a VA orthopedic surgeon documented left knee flexion limited to 100 degrees and full extension (0 degrees). In December 2017 and June 2018 VA Orthopedic Surgery Notes, an orthopedic surgeon documented left knee flexion limited to 90 degree and full extension (0 degrees) on each date. None of the Veteran's medical records document that her left knee displayed compensable limitations of flexion or extension. Based on the evidence of record, the Board finds that the Veteran's left knee flexion or extension did not manifest to a compensable degree of limitation during the claim period. Therefore, her current assigned disability rating of 10 percent based on pain and limitation of motion under 38 C.F.R. § 4.59 is appropriate. She is not entitled to a higher disability rating for her left knee arthritis. 5. From September 27, 2016, an initial disability rating of 20 percent, but no higher, for right knee lateral instability is granted. 6. From September 27, 2016, an initial disability rating of 20 percent, but no higher, for left knee lateral instability is granted. Rating Criteria Knee (lateral instability) The Veteran seeks an initial determination as to whether her right and left knee should receive ratings based on instability. Stability of the knee is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5257. On February 7, 2021, VA enacted new rating criteria for Diagnostic Code 5257. Because the Veteran's claims for an increased disability rating for her knees have been pending since she filed her initial claim for service connection in 2011, the Board is required to analyze her claims under each version of Diagnostic Code 5257 from February 7, 2021, onward, and which ever version provides her the greater benefit will be applied from that point. See Ervin, 24 Vet. App. 318. Prior to February 7, 2021, 38 C.F.R. § 4.71a, Diagnostic Code 5257 provided as follows: Rating (%) Knee, other impairment of: Recurrent subluxation or lateral instability: Severe 30 Moderate 20 Slight 10 Subluxation is "an incomplete or partial dislocation." Dorland's Illustrated Medical Dictionary 1791 (32d ed. 2012). Lateral instability generally refers to an acute injury or chronic repetitive stress resulting in attenuation and alteration of the mechanical structures of the ligaments surrounding the knee. See Torn lateral collateral ligament, MedlinePlus Medical Encyclopedia, U.S. National Library of Medicine, https://medlineplus.gov/ency/imagepages/8842.htm (last accessed Nov. 19, 2021). VA regulations do not define the terms "slight," "moderate," or "severe." Absent an express definition, it is presumed that VA regulations employ words using their ordinary dictionary meanings at the time the regulations were promulgated. See Nielson v. Shinseki, 607 F.3d 802, 80506 (Fed. Cir. 2010). "Slight," as an adjective, is defined as "small of its kind or in amount." Slight, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/slight, Definition 2, (last visited Nov. 21, 2021). "Moderate," as an adjective, is defined as "not violent, severe, or intense"; "limited in scope or effect." Moderate, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/moderate, Definitions 3 and 5 (last visited Nov. 21, 2021). "Severe," as an adjective, is defined as "causing discomfort or hardship"; "very painful or harmful"; "of a great degree." Severe, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/severe, Definitions 6a, 6b, and 8 (last visited Nov. 21, 2021). Using the above definitions as guidance, the Board must arrive at an equitable and just decision based on an evaluation of all relevant evidence. 38 C.F.R. §§ 4.2, 4.6. It should also be noted that use of terminology such as "slight," "moderate," and "severe" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. In addition, objective evidence is not required to assign a disability rating under DC 5257. See English v. Wilkie, 30 Vet. App. 347, 353 (2018) ("[N]othing in [Diagnostic Code] 5257 provides that objective medical evidence is required or is to be favored over lay evidence . . . . '[I]t certainly does not, by its terms, restrict evidence to "objective" evidence.'" (quoting Petitti v. McDonald, 27 Vet. App. 415, 427 (2015))). Diagnostic Code 5257, effective February 7, 2021, now provides: Rating (%) Knee, other impairment of: Recurrent subluxation or lateral instability: Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. 30 One of the following: 20 (a) Sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. (b) Unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. 10 Patellar instability: A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. 30 A diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. 20 A diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. 10 Note (1): For patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note (2): A surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration). Analysis In a September 27, 2016, VA Physical Therapy Note, a medical professional recorded that the Veteran's right and left knee displayed mild laxity of the anterior cruciate ligaments (ACL). Her right medial collateral ligament displayed moderate laxity and her lateral collateral ligament displayed mild laxity. Her left medial and lateral collateral ligaments displayed mild to moderate laxity. Her right knee had medical side movement. During her February 2018 Board hearing, she testified that she experienced swelling, locking, and giving out of her knees. The Veteran's VA and VA-contracted examiners did not record evidence of lateral instability or subluxation. Yet, she consistently reported feelings of instability in her knees. Prior to September 27, 2016, the Board finds insufficient evidence of bilateral knee recurrent subluxation or lateral instability. The Board acknowledges the Veteran's lay statements about her experiences with general feelings of instability but due to the lack of lay or medical evidence discussing the duration, frequency, or severity of such symptoms, the Board finds the evidence of record is mere speculation as to whether she experienced recurrent subluxation or lateral instability prior to September 27, 2016. From September 27, 2016, the Board resolves reasonable doubt in the Veteran's favor and finds that her right and left knee most closely displayed moderate lateral instability. The most probative evidence of record is the September 27, 2016, VA Physical Therapy Note documenting mild to moderate instability of the bilateral knees. The Board finds that the medical documentation when coupled with the Veteran's statements about her swelling, locking, and giving way, represents moderate lateral instability. Notably, the Veteran used and continues to use knee braces on a regular basis. The evidence does not establish severe instability because the Veteran has maintained the ability to walk, work, and otherwise engage in daily activities despite her bilateral knee instability. From February 7, 2021, the Board finds the prior version of Diagnostic Code 5257 is more beneficial to the Veteran. Under the new version, in order to receive a 30 percent disability rating, the Veteran must have had: (1) an "unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation" or (2) "a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker." The Veteran has not had an unrepaired or failed repair of complete ligament tear or either knee, nor has she undergone surgical repair on either knee. Therefore, an increased disability rating under Diagnostic Code 5257 in effect as of February 7, 2021, is not available. 7. An initial compensable disability rating of 10 percent, but no higher, for service-connected right shin splints is granted. 8. An initial compensable disability rating of 10 percent, but no higher, for service-connected left shin splints is granted. The Veteran's bilateral shin splints are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5262 ("Tibia and fibula, impairment of"). This Code has also been amended as of February 7, 2021. Prior to February 7, 2021, Diagnostic Code 5262 provided: Rating (%) Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace 40 Malunion of: With marked knee or ankle disability 30 With moderate knee or ankle disability 20 With slight knee or ankle disability 10 VA regulations do not define the terms "slight," "moderate," or "marked." Thus, the Board turns to dictionary definitions for assistance. Nielson, 607 F.3d at 80506. "Slight," as an adjective, is defined as "small of its kind or in amount." Slight, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/slight, Definition 2, (last visited Nov. 21, 2021). "Moderate," as an adjective, is defined as "not violent, severe, or intense"; "limited in scope or effect." Moderate, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/moderate, Definitions 3 and 5 (last visited Nov. 21, 2021). "Marked," as an adjective, is defined as "having a distinctive or emphasized character." Severe, Merriam-Webster Dictionary Online, https://www.merriam-webster.com/dictionary/marked, Definition 2 (last visited Nov. 21, 2021). Malunion is "union of the fragments of a fractured bone in a faulty position." Dorland's Illustrated Medical Dictionary 1115 (31st ed. 2007). Nonunion is the "failure of the ends of a fractured bone to unite." Id. at 1309. Disability from malunion of the tibia shaft is produced mainly by rotational deformity, lateral and posterior bowing, and usually some degree of shortening. See Canale & Beaty, Campbell's Operative Orthopaedics 2931 (12th ed. 2012). Symptoms may include ankle, knee, or back pain, gait disturbances, and a cosmetically unacceptable deformity. Id. A malunited fracture may also impair function by blocking the movements of the neighboring joints. Id. Looking to the plain meaning of the terms used in the rating criteria, "disability" means "incapacity or lack of ability to function normally" that may be either physical, mental, or both, including anything that causes such incapacity. Dorland's Illustrated Medical Dictionary at 533. The regulatory definition of "disability" is the "impairment of earning capacity resulting from such diseases or injuries and their residual conditions." 38 C.F.R. § 4.1. Furthermore, "impairment" is "any abnormality of, partial or complete loss of, or the loss of the function of, a body part, organ, or system" that is "due directly or secondarily to pathology or injury and may be either temporary or permanent." Dorland's Illustrated Medical Dictionary at 936. Thus, the requirement of knee or ankle "disability" is broad enough to encompass all symptoms, including pain, limitation of motion, stiffness, and instability. The other requirement for a compensable rating under Diagnostic Code 5262 is that there be malunion or nonunion of the tibia and fibula. Using the above definitions as guidance, the Board must arrive at an equitable and just decision based on an evaluation of all relevant evidence. 38 C.F.R. §§ 4.2, 4.6. The Board keeps in mind that the terms "slight," "moderate," and "marked" are used in relation to a knee or ankle disability. Use of terminology such as "mild," "moderate," and "marked" by VA examiners or other physicians, although an element of evidence to be considered by the Board, is not dispositive of an issue. In addition, objective evidence is not necessarily required to assign a disability rating under Diagnostic Code 5262. See Petitti, 27 Vet. App. at 427. As of February 7, 2021, Diagnostic Code 5262 now provides: Rating (%) Tibia and fibula, impairment of: Nonunion of, with loose motion, requiring brace 40 Malunion of: Evaluate under diagnostic codes 5256, 5257, 5260, or 5261 for the knee, or 5270 or 5271 for the ankle, whichever results in the highest evaluation. Medial tibial stress syndrome (MTSS), or shin splints: Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, both lower extremities 30 Requiring treatment for no less than 12 consecutive months, and unresponsive to surgery and either shoe orthotics or other conservative treatment, one lower extremity 20 Requiring treatment for no less than 12 consecutive months, and unresponsive to either shoe orthotics or other conservative treatment, one or both lower extremities 10 Treatment less than 12 consecutive months, one or both lower extremities 0 Notably, "shin splints" are now specifically listed as a disability with defined criteria. Analysis The Board has reviewed the evidence of record and finds that the evidence supports the award of an initial disability rating of 10 percent, but no higher, for bilateral shin splints under the version of Diagnostic Code 5262 in effect prior to February 7, 2021. The Board finds that the version of Diagnostic Code 5262 in effect prior to February 7, 2021, is more beneficial to the Veteran because her symptoms associated with her shin splints have not included "treatment for no less than 12 consecutive months, and unresponsive[ness] to surgery and either shoe orthotics or other conservative treatment, one lower extremity" since February 7, 2021. Therefore, she would not be entitled to a higher disability rating of 20 percent or more under the current version of Diagnostic Code 5262. During the entire claim period, the evidence shows that the Veteran had bilateral shin splints that slightly affected her range of motion of her bilateral ankles. Her medical records reflect functional limitation of the right and left ankle due to pain. See generally, e.g., 2012 VA Medical Note (bilateral ankle pain and swelling); April 2014 VA Physical Therapy Note (marked bilateral stiffness with tibial involvement); September 2016 VA Physical Therapy Note (bilateral ankle braces used for stability); August 2021 VA Problems list (equinus contracture of the ankle). As this evidence demonstrates malunion of the tibia and fibula with a slight bilateral ankle disability, a 10 percent rating is warranted. The Board notes that the Veteran is service connected for right and left knee disabilities and has been assigned disability ratings based on functional limitation of her bilateral knees. Accordingly, the Veteran may not be assigned separate ratings under both Diagnostic Codes 5262 and either 5260 or 5261. These codes overlap in rating based on the symptom of painful motion or limitation of motion, in this case, limitation of flexion and extension, because the rating criteria under Diagnostic Code 5262 rates, in part, based on limitation of motion due to malunion. To assign separate ratings under both codes would compensate the Veteran twice for the same symptomatology, here, limitation of flexion and extension, including limitation of motion due to pain. 38 C.F.R. § 4.14. Thus, the Board may only consider the extent her bilateral ankles relate to her shin splints. The evidence is against the award of an increased rating in excess of 10 percent for bilateral shin splints. The evidence shows that the Veteran's bilateral shin splints are manifested with pain and limitation of motion, but do not result in malunion of the tibia and fibula with moderate ankle disability. While her bilateral ankles displayed pain, swelling, and limitation of motion, there was no evidence of compensable limitation of motion. As the Veteran's limitation of motion for her ankles is, by itself, noncompensable, the Board finds that the bilateral shin splints do not result in a moderate ankle disability. Overall, the Veteran maintained her ability to walk, work, and engage in daily activities despite her bilateral shin splints. In sum, the evidence shows that a 10 percent rating for bilateral shin splints is warranted, and the claim is granted to this extent. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran's claim for an increased rating in excess of 10 percent is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 9. Prior to June 22, 2017, an increased initial disability rating in excess of 30 percent for service-connected depression is denied. 10. From June 22, 2017, and increased disability rating of 70 percent, but no higher, for service-connected depression is granted. Rating Criteria Depression Under the General Formula for Mental Disorders (General Formula), 38 C.F.R. § 4.130, the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017). The symptoms listed in the VA's general rating formula for mental disorders are not intended to constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, which would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436 (2002). The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 11418 (Fed. Cir. 2013). The General Formula, 38 C.F.R. § 4.130, DC 9435, provides, in pertinent part, as follows: Rating (%) Total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. 100 Occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. 70 Occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 50 Occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). 30 38 C.F.R. § 4.130, Diagnostic Code 9435 does provide for ratings lower than 30 percent. In this case, however, the Veteran received an initial disability rating of 30 percent. Thus, an analysis of the ratings lower than 30 percent is unwarranted, absent legal and factual bases to issue a reduction in the Veteran's current rating. See 38 C.F.R. § 3.344. Considerations in rating a mental disorder include the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126(a). The rating must be based on all evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of the examination. Id. Although the extent of social impairment is a consideration in determining the level of disability, the rating may not be assigned solely on the basis of social impairment. 38 C.F.R. § 4.126(b). The United States Court of Appeals for the Federal Circuit held that evaluation under 38 C.F.R. § 4.130 is "symptom-driven," meaning that "symptomatology should be the fact-finder's primary focus when deciding entitlement to a given disability rating." Vazquez-Claudio, 713 F.3d at 11617. Analysis Prior to June 22, 2017 During a July 2011 VA psychiatric examination, the examiner documented that the Veteran did not display any abnormal behavior other than being emotional when discussing her situation. She did not exhibit any unusual movements or psychomotor changes. Her speech was within normal limits. Her affect appeared tearful and dysphoric, and she cried frequently throughout the evaluation when discussing her military disappointment. She described her mood as angry. Her thought processes were goal-directed and logical. She did not exhibit any disturbances of thought content or perception. She denied suicidal or homicidal ideation, plan, or intent. She was oriented. Her memory and concentration appeared to be grossly intact. Her insight and judgment appeared to be fair to good. She was able to maintain activities of daily living as her symptoms were intermittent. He thought processes, communication ability, and social functioning were not impaired. The examiner opined her symptoms were transient or mild, occurring only during periods of significant stress. They were not severe enough to require continuous medication and not severe enough to interfere with occupational and social functioning. An August 2011 medical record noted "memory lapses or loss: etiology unclear, she reports that she sleeps well. Depression could be contributing to memory changes." February 2012, May 2013, February 2014, March 2014, June 2015, June 2016, and May 2017 mental health screens did not record reports of hopelessness, suicidal ideations, or other depressive symptoms. Her medical records are silent for other significant mental health symptoms associated with her depression prior to June 22, 2017. She was documented as having normal mood and affect, and she was oriented and did not have impaired thought processes during this claim period. For the period prior to June 22, 2017, the Board finds no credible and probative evidence that the Veteran's depression resulted in occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. Her depression was mild during this period, she had no manifestations that affected her social or occupational activities as contemplated by the 50 percent rating criteria (or higher) based on the lay and medical evidence of record. While she had memory lapse/loss, there is no indication in the record that it affected her occupational or social functioning such that it made her depression more closely resemble the 50 percent rating criteria. The Board notes that the Veteran received an initial 30 percent disability rating for her depression based on her Global Assessment Functioning (GAF) score of 68 during the July 2011 VA examination. Relevant to this case, for all appeals certified to the Board after August 4, 2014, VA moved from using the Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition (DSM-IV) to using the Diagnostic and Statistical Manual for Mental Disorders, Fifth Edition (DSM-5). See 80 Fed. Reg. 14,308 (Mar. 19, 2015). A key difference between the DSM-IV and the DSM-5 is that the newer edition no longer employs GAF scores to assess the effect of a mental disorder on a person suffering from such a condition. Golden v. Shulkin, 29 Vet. App. 221, 225 (2018). GAF scores are no longer considered an acceptable metric. See id. Accordingly, prior to June 22, 2017, an increased initial disability rating in excess of 30 percent for service-connected depression is not warranted based on the evidence of record. From June 22, 2017 On June 22, 2017, the Veteran received a VA examination to assess the severity of her depression. During the examination, she reported depression, poor concentration, irritability, being impatient, fleeting thoughts of suicide, fatigue, overeating, psychomotor agitation/retardation nearly every day, sleep disturbance, mild memory loss (such as forgetting names, directions, or recent events), low self-worth more than half the days, infrequent panic attacks. She continued to work and maintained activities of daily living, including hygiene. There were no abnormal physical or mental behaviors, and the Veteran's appearance was normal. Overall, the examiner opined that the Veteran's depression resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care and conversation. From September 2017 to October 2017, the Veteran reported to VA medical professionals during various treatments that she had feelings of depression, trouble sleeping, appetite issues, feeling of guilt/failure, trouble concentrating, and motor retardation/agitation for several days a week. In an October 2017 VA medical note, the Veteran endorsed suicidal ideations more than half of the days in a week. During her February 2018 Board hearing, she testified about experiencing suicidal thoughts on a daily basis. She had no interest in social and occupational activities. Her depression was causing procrastination, which interfered with her work. In April 2018, she received a VA-contracted examination assessing her depression. The examiner documented symptoms of depressed mood, mild memory loss, and no evidence abnormal physical or emotional behavior, to include though process, speech, hallucinations, or appearance. She continued to work and take care of her family. The examiner opined that the Veteran's depression resulted in occupational and social impairment due to mild/transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. In her 2019 VA medical records, it was documented that the Veteran began experiencing suicidal ideations once again due to medications, which decreased once she decreased her medications. Her mood fluctuated. She received a VA-contracted examination in April 2021. That examiner recorded symptoms of depressed mood, chronic sleep impairment, mild memory loss, and no evidence of abnormal thought or speech, to include hallucinations. The examiner opined that the Veteran's depression resulted in occupational and social impairment due to mild/transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress, or symptoms controlled by medication. Resolving reasonable doubt in the Veteran's favor, the Board finds that from June 22, 2017, the Veteran's depression manifested more closely as occupational and social impairment, with deficiencies in most areas. In particular, her lack of concentration has interfered with her social and occupational activities to a larger extent than contemplated by the 50 percent rating criteria. This is more evident when the Board considers the effect her suicidal ideations have had on her well-being. Therefore, a disability rating of 70 percent is granted from June 22, 2017. A rating of 100 percent is not warranted in this case because the Veteran's depression as not manifested as total social and occupational impairment as evidenced by her continued ability to work and care for her family. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. F. Sawka, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.